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THE PRACTICE OF MEDICINE 




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THE 



PRACTICE OF MEDICINE 



BY 

EDWIN M. HALE, M.D.. 

AUTHOR OF "THE NW REMEDIES"; "DISEASES OF THE HEART"; "DISEASES OF WOMEN 

"THE HEART, AND HOW TO TAKE CARE OF IT." EMERITUS PROFESSOR OF THE 

THEORY AND PRACTICE OF MEDICINE IN THE CHICAGO HOMEOPATHIC 

MEDICAL COLLEGE; MEMBER OF THE AMERICAN INSTITUTE 

OF HOMEOPATHY; THE ILLINOIS ASSOCIATION OF 

HOMEOPATHIC PHYSICIANS, Etc., Etc., Etc. 



The highest aim of healing is the speedy, gentle, and permanent restitution of health, 
or alleviation and obliteration of disease in its entire extent, in the shortest, most reliable, 
and safest manner, according to clearly intelligible reasons, — Hahnemann. 







CHICAGO 
GROSS AND DELBRIDOE 

:No. 48 fmafcison Stmt 
1894 






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Copyright 1894 
GROSS AND DELBRIDGE 



PREFACE 



The aim of this book is to present to the physician the most prac- 
tical way of treating disease by medicinal and hygienic methods. 
To do this I have drawn upon my experience as a general practi- 
tioner for forty years : and upon the experience and observation of 
my colleagues of all schools of practice, so far as I believed them 
trustworthy. I entertain the broad belief that while the law of Sim- 
ilia is the chief guide in the selection of drugs, there are other meth- 
ods of cure which should not be neglected. TThile I believe the 
application of the law of Similars is very wide, I know that it has 
its limitations ; that remedial medicaments which act chemically and 
physiologically cure some diseases promptly and safely. In the light 
of our present knowledge of ferments and micro-organisms, we know 
that many diseases require medicines which destroy the germs which 
are the cause of diseases ; and that unless such agents are used con- 
jointly with strict aseptic measures the most carefully chosen medi- 
cines are powerless to cure. 

It is my conviction that the physician who selects his remedies 
in accordance with the law of Similia, and by their primary symptoms 
alone, narrows his therapeutic resources, and deprives his patients 
of means of cure which it is his duty to apply. By clinging to one 
and rejecting all other methods of cure, the physician fails in his 
duty to his patients. 

If I have quoted freely from writers of all systems of practice, I 
have done so because I have desired to give the best information at 
present attainable, and I have been careful to give due credit to all 
authorities. 

This is an era of preventive medicine. The physician who pre- 



viii. PREFACE. 

vents disease is worthy of equal, if not more, honor than one who 

cures. Therefore I have made hygiene as prominent as medicinal 

therapeutics. In relation to dose, I have left the size and repetition 

to the individual experience and observation of the practitioner, 

except in cases where my own experience warranted me in giving 

explicit directions. My conviction is that any dose, from the crude 

drug to the most minute particle of a drug, may prove curative. 

There is no fixed law regulating dose, and there never will be. 

The best criticism I desire for this book and myself is that I 

have been honest, liberal, and conscientious. 

E. M. H. 

Chicago, March 1, 1894. 

No. 65 East Twenty-second street. 



CONTENTS, 



PAGE. 



CHAPTER I. 

FEVERS. 

Ephemeral Fevers 1 

Malarial Fevers 2 

Simple Intermittent 2 

Remittent 10 

Pernicious 11 

Typho-malarial 14 

Typhus Fever 15 

Relapsing Fever 16 

Dengue Fever 16 

Typhoid Fever 17 

Sewer-gas Fever 28 

Rocky-Mountain Fever 32 

Yellow Fever 35 

CHAPTER II. 

INFECTIOUS ERUPTIVE FEVERS. 

Small-pox (Variola) 37 

Varioloid . 39 

Varicella (Chicken-pox) 39 

Scarlet Fever 40 

Rubeola (Measles) 46 

Epidemic Roseola 51 

CHAPTER III. 
SPECIFIC INFECTIOUS DISEASES. 

Diphtheria 53 

Erysipelas 63 

La Grippe 67 

Whooping-cough 72 

Parotitis 76 

Idiopathic Parotitis (Mumps) 76 

Symptomatic Parotitis 78 

Carbuncle 78 



x. CONTENTS. 

Tetanus 80 

Syphilis • 83 

Dysentery 85 

Cholera Asiatiea ' 95 

Tuberculosis, Scrofula, Phthisis 107 

Acute Tuberculosis 110 

Scrofula (Tuberculosis of the Lymph Glands) 110 

Pulmonary Tuberculosis Ill 

Gonorrhoea 135 



CHAPTER IV. 
CONSTITUTIONAL DISEASES. 

Rheumatism 139 

Anaemia 146 

Primary Anaemia 147 

Secondary Ansemia 148 

Corpulency 162 

Mal-nutrition, Emaciation, Leanness 171 

Diabetes Mellitus 174 

Diabetes Insipidus 191 

Myalgia 194 

Gout 196 

Diseases of the Thyroid Gland . » 201 

Acute Inflammation 201 

Congestion or Engorgement 201 

Goitre (Bronchocele) 202 

Myxcedema 207 

Septicaemia 209 

Pyaemia 210 

Purpura 212 

Haemophilia 216 

Scurvy (Scorbutus) 217 

Infantile Scurvy 218 

Osteomalacia 223 

Rickets 227 

Furuncle 237 



CHAPTER V. 
DISEASES OF THE RESPIRATORY SYSTEM. 

Acute Coryza 239 

Chronic Coryza 242 

Hay Fever 254 



CONTENTS. xi. 

Cough 258 

Hypersesthetic Pharyngitis 268 

Acute Laryngeal (Edema 271 

Nasal Stenosis 273 

Epistaxis 276 

Laryngitis Stridulosa 277 

Acute Catarrhal Laryngitis 280 

Chronic Laryngitis 282 

Membraneous Laryngitis 284 

Bronchial Spasmodic Asthma 292 

Bronchitis 305 

Acute Catarrhal Bronchitis 306 

Chronic Bronchitis 307 

Diseases of the Ltfngs 325 

Congestion of the Lungs 325 

(Edema of the Lungs 328 

Hemorrhage from the Lungs 330 

Broncho-pneumonia (Capillary Bronchitis) ......... 336 

Pneumonia 342 

Gangrene of the Lungs 349 

Emphysema 350 

Abscess of the Lungs 352 

Diseases of the Pleura 353 



CHAPTER VI. 

DISEASES OF THE DIGESTIVE SYSTEM. 

Diseases of the Mouth 361 

Stomatitis • 361 

Diseases of the Salivary Glands 364 

Diseases of the Tonsils 365 

Diseases of the (Esophagus 369 

Diseases of the Stomach 370 

Acute Gastritis 370 

Chronic Gastritis 372 

Dilatation of the Stomach 382 

Neurosis of the Stomach (Gastralgia) 384 

Hemorrhage from the Stomach 387 

Ulcer of the Stomach and Duodenum 389 

Cancer of the Stomach 394 

Diseases of the Intestines 396 

Catarrhal Enteritis (Diarrhoea) 396 

Diarrhoea of Children 401 



xii. CONTENTS. 

Diseases of the Intestines — Continued. 

Acute Dyspeptic Diarrhoea 401 

Cholera Infantum 405 

Appendicitis 408 

Membraneous Colitis 416 

Constipation 418 

Intestinal Obstruction 424 

Diseases of the Rectum — Non-surgical 426 

Hygiene of the Rectum 427 

Hemorrhoids, Piles 432 

Internal Hemorrhoids 434 

Procidentia Recti 437 

Fissure and Ulcer of the Rectum 440 

Diseases of the Sacculi Horneri 444 

Diseases of the Rectal Papillae 447 

Proctitis 447 

Proctalgia • 450 

Pruritus Ani 450 

Diphtheria of the Rectum 453 

Peritonitis 453 

Ascites 456 

Diseases of the Liver 458 

Functional Disorders 458 

The Action of Medicinal and Other Substances on the Liver . . . 464 

Lithsemia 474 

Increased Secretion and Expulsion of Bile 487 

Biliousness 490 

Congestion of the Liver . . . , 505 

Hepatic Congestion in Children 511 

Jaundice without Obstruction 512 

Icterus (Jaundice) 518 

Gall-stones 526 

Acute Hepatitis 547 

Cirrhosis of the Liver 550 

Fatty Liver 552 

Cancer of the Liver 553 

Diseases of the Pancreas 553 

Acute Pancreatitis . . , 554 

Suppurative Pancreatitis 555 

Diseases of the Spleen 560 

Congestion 560 

Inflammation 563 

Splenalgia 565 

Hypertrophy of the Spleen 566 



CONTENTS. xiii. 

CHAPTER VII. 
DISEASES OF THE URINARY SYSTEM. 

Diseases of the Kidneys 569 

Nephralgia 569 

Congestion of the Kidneys 570 

Hematuria 571 

Hemoglobinuria 575 

Nephrolithiasis (Renal Calculus) 576 

Nephritis (Bright 's Disease) 585 

Acute Diffuse Nephritis 585 

Chronic Parenchymatous Nephritis 589 

Chronic Interstitial Nephritis 591 

Pyelitis 619 

Uramiia 622 

Diseases of the Bladder 624 

Acute Cystitis 624 

Chronic Cystitis 628 

Vesical Disorders of Women 638 

Irritable Bladder and Urethra 642 

Incontinence of Urine 647 

Retention of Urine 654 

Acute Inflammation of the Prostate Gland 656 

Chronic Inflammation of the Prostate Gland 661 

Hypertrophy of the Prostate Gland 666 

Atrophy of the Prostate Gland 676 

CHAPTER VIII. 

DISEASES OF THE CIRCULATORY SYSTEM. 

Inflammations of the Heart 680 

Pericarditis, Endocarditis, Myocarditis 680 

Chronic Valvular Diseases 683 

Aortic Incompetency 684 

Aortic Stenosis 687 

Mitral Stenosis 689 

Hypertrophy and Dilatation 690 

Essential Paroxysmal Tachycardia 691 

Persistent Tachycardia 701 

Bradycardia 724 

The Senile Heart . 731 

Pain in the Heart 746 

Angina Pectoris 749 

The Heart in Pneumonia 756 



xiv. CONTENTS. 

High Arterial Tension 768 

Low Arterial Tension 779 

The Pulse 787 

What the Pulse Really Is 788 

The Action of the Heart 791 

Mode of Feeling the Pulse 793 

Irregular Pulse 799 

Intermittent Pulse 801 

Diseases of the Veins 803 

Phlebitis 803 

Thrombosis of the Veins 804 

Dilatation of the Veins (Varix) 807 

Embolism , 812 

Thrombosis of the Heart and Arteries 813 

Arterio-Sclerosis 814 

Geography of Heart Disease 821 

!Non-medicinal Methods of Treating Diseases of the Heart 826 

Sehott's Method of Treatment of Chronic Diseases of the Heart .... 828 



CHAPTER IX. 

DISEASES OF THE NERVOUS SYSTEM. 

Laryngismus Stridulus 832 

Paralysis Agitans 834 

Chorea 837 

Cardiac Chorea 847 

Chorea in Pregnancy 847 

Epilepsy 850 

Hysteria 857 

Neurasthenia 862 

Insomnia 871 

Sunstroke 880 

Diseases of the Brain and Nerves 884 

Irritation of the Brain 884 

Cerebral Hyperemia 886 

Cerebral Anaemia 891 

Headache 896 

From Cerebral Hyperemia 901 

Sympathetic Headache 902 

Bilious Headache 905 

From Eye Strain 907 

Nervous Headache 909 

Toxsemic Headache 912 

Cerebral Hemorrhage 915 



CONTEXTS. xv. 

Diseases of the Brain and Nerves — Continued. 

Tumors of the Brain 917 

Meningitis, Acute-Simple 919 

Meningitis, Cerebro-Spinal 922 

Spinal Hypereemia 929 

Spinal Anaemia , . 931 

Neuralgia 936 

Cervico-occipital ' 944 

CerYico-brachial 944 

Intercostal 946 

Lumbar 949 

Sciatic 951 

Neuritis 958 

Localized Neuritis 959 

Multiple Neuritis (Polyneuritis) 960 

Alcoholic Neuritis 964 

Lead and Arsenic Neuritis 965 

Endemic Neuritis (Beri-Beri) 966 

Neuromata 967 

Myelitis 967 

Myelitis, Acute, of the Anterior Horns 969 

Multiple Sclerosis of the Brain and Spinal Cord 973 

Chronic Diffuse Meningo-Encephalitis 974 

Chronic Degenerations of the Spinal Cord 978 

Locomotor Ataxia (Tabes Dorsalis) 978 

Primary Spastic Paraplegia 984 

Ataxic Paraplegia 985 

Hereditary Ataxia 987 

Pellagra 988 

Progressive Spinal Muscular Atrophy 989 

Bulbar Paralysis 992 

Pseudo-Hypertrophic Muscular Paralysis 993 

Syringo Myelia 996 

Tumors of the Spinal Cord 997 

Spina Bifida 997 

Nerve Vibration 998 



CHAPTER X. 

INTESTINAL PARASITES. 

Ascaris Lumbricoides 1004 

Oxyuris Veraiicularis 1008 

Tape- Worms and Cyst "Worms 1012 



THE 

PRACTICE OF MEDICINE. 



CHAPTER I 

FEYERS. 



EPHEMERAL FEVER. 

This fever, sometimes called " simple," is a non-specific fever, either 
remittent or continuous, which runs its course in a few days, and 
terminates in a rapid convalescence ; presenting no characteristic 
lesion, and seldom any premonitory symptoms, its access being 
sudden. It may be caused by mental emotions, by extremes of 
heat and cold, by excessive mental and physical fatigue. It may 
last a few days, or a few weeks ; and it is impossible to predict, in 
the beginning, whether the fever is simple, or has a specific cause. 
Not until indications of some local lesion occur, can we make a 
diagnosis. It is often remittent, the temperature being nearly nor- 
mal in the morning, and rising to 103° or 105° F. in the evening. 
If it occurs in a malarial region, and during the months when 
malaria obtains, it may be confused with miasmatic fever. 

Treatment. — If the patient is robust and strong, little or no food 
is necessary ; only plenty of cool pure water, a cool well- ventilated 
room, and cool or warm sponging. To weakly patients, gruels, 
broths, fresh milk, or wine-whey, may be given. If there is a sus- 
picion of noxious matter in the digestive tract, it should be removed 
by an enema, aided by a simple laxative, like seltzer aperient, con- 
gress water, or phosphate of soda. 

Aconite is sufficient in nearly all cases, particularly if there is 
anxiety, dry heat, and a small hard pulse ; or if the fever is due to 
fright or mental excitement. 

Gelsemium is equally efficacious if the fever occurs from ex- 
posure to rapid changes of cold or heat, and especially if the febrile 
movement tends towards a distinctly remittent type. Other indica- 



2 THE PRACTICE OF MEDICINE. 

tions are a flushed, bright-red face, a hot but moist skin, and a quick, 
but soft, large pulse. Even if decidedly miasmatic in origin, this 
drug will modify or arrest it. 

Veratrum viride is a potent remedy in robust persons, when the 
temperature reaches 104° or 105° F., and the pulse is large, hard, 
and bounding. 

Bryonia is adapted to those cases which seem bilious or rheu- 
matic, with acute pains all over, worse on movement, with dull, 
stupefying headache, but with a temperature rarely above 103° F. 

Phenacetin, in doses of two or three grains, will relieve the aches 
and pains sooner than any other remedy. 

Eupatorium perfoliatum is an excellent remedy when the fever 
assumes a decidedly bilious character, such as is commonly called 
" bilious fever," occurring in the summer and autumn months, re- 
mittent in character, with vomiting and purging of acrid green mat- 
ter, violent aching, apparently " in the bones." If the fever is 
miasmatic, it acts equally well. 

Mercurius and ipecac, for many years a very successful remedy 
in my practice, has been a combination of the 2x trituration of these 
two drugs, especially when the tongue is foul, brown, or "pasty," 
the breath offensive, the bowels confined or loose, and when there is 
great nausea or vomiting, but only a moderate fever ; then a few 
grains every two hours will soon effect a favorable change. These 
remedies can be used in alternation, if that method be preferred. 

MALARIAL FEVERS. 

I.— SIMPLE INTERMITTENT FEVER. 

A paroxysmal disease, due to the action of a malarial poison, 
supposed to be a bacillus, characterized by the occurrence of febrile 
paroxysms, consisting of a succession of definite stages, namely, 
the cold, the hot, and the sweating stage, separated by an apyrexia, 
or intermission of variable length. According to the length of the 
interval, the fever may be of different types, hence the names : Quo- 
tidian, tertian, or quartan, i. e., a fever every day, every second 
day, or every fourth day. These are typical forms, but there are 
many atypical forms ; I have seen the paroxysms occur twice a day, 
every three days, every fifth, sixth, and seventh day, and even every 



FEVERS. 3 

fourteenth day. More singular still are those forms termed " masked 
ague," when the paroxysms may assume as many forms as the trans- 
formations of the fabled Proteus, forms in which there is no chill, 
fever, or sweat, but instead, periodical attacks of headache, eyeache, 
earache, neuralgia of any organ, gastralgia, cardiac disorder, diar- 
rhoea, dysentery, swelling of a joint, imitating rheumatism, ovarian 
pain, hemorrhages from various organs, and even paroxysmal insan- 
ity ; all these manifestations, and many more, I have seen occur ; not 
only have I seen them occur uncomplicated with other diseases, but 
I have seen non-malarial disorders change to malarial, and have seen 
the malarial paroxysms engrafted upon, and mix and mingle with, 
non-malarial disorders. There is no form of disorder that it may 
not assume or imitate. Why the malarial should cause this periodi- 
city, — varying in different cases, — or why it should assume so many 
different forms, has not been satisfactorily answered. Laveran's 
hypothesis is that the paroxysms coincide with the development of 
the bacillus malarise, but he does not explain why the paroxysms 
occur without fever or chill, or why these manifestations are often 
located in some particular nerve, or joint, or organ of the body. 
What, for example, has the bacillus to do with an attack of hema- 
turia, hysteria, or paroxysm of mania? Again, why do these par- 
oxysms persist long after the bacilli are supposed to have left the 
system? No fact is better known than that malarial fever is not 
contracted after the occurrence of frost, or after the temperature re- 
mains constantly below 50° F. ; yet patients that have been the 
victims of ague, often continue to have paroxysms similar to genuine 
ague, all through the winter ; these attacks are commonly called 
dumb-ague. My explanation is that the nervous system is naturally 
prone to paroxysmal manifestations, as in periodic neuralgia not due 
to malaria, and that the post-malarial paroxysms are kept up by a 
habit into which certain nerves have fallen. There is a peculiarity 
of these post-malarial paroxysms that has created an element of great 
uncertainty in the therapeutics of ague, namely, that the paroxysms 
can be arrested by suggestion, by mental shock, change of environ- 
ment, etc. This accounts for the multiplicity of remedies which are 
supposed to cure or to arrest the paroxysms ; many of these are as 
absurd as are the alleged " cures " for warts. I have known the 
setting back the hour-hand of the clock prevent the access of the 



4 THE PRACTICE OF MEDICINE. 

paroxysm ; the belief of the patient that he has passed the hour of his 
chill is often sufficient to prevent a paroxysm of " ague from habit." 
Treatment. — The treatment of Intermittent Fever has been a 
bone of contention in the homeopathic school, the extremists con- 
tending that we should select medicines according to the totality of 
the symptoms, ignoring altogether the element of periodicity. These 
physicians claim success, even in pernicious cases ; but I cannot be- 
lieve it, because for several years I tried faithfully, with painful 
study, to treat ague after that plan. I did not succeed ; sometimes 
the paroxysms ceased on the seventh or fourteenth day, as they will 
do even if left to nature ; often they assumed a remittent character, 
but oftener my patients took the case into their own hands, and swal- 
lowed quinine ad libitum, or employed another physician, who pre- 
scribed quinine ad libitum. Dr. Kippax (" Lectures on Fevers ") 
gives indications for more than fifty remedies ; Bcenninghausen, 
over one hundred ; Allen, many more. This is absurd. Of all 
these, only ten are of any special practical value ; the dogma that 
any remedy, the symptoms of which possess those of intermittent 
(excepting the periodicity^), will cure ague, is an illusion. I shall 
not attempt to argue the question ; this opinion is the result of 
experience and observation ; if the individual experiences of others 
are to the contrary, I shall not try to controvert such experience. 
Kippax says : " Our sheet anchor in the treatment of simple inter- 
mittent is quinine." But when he says that it is " for no other reason 
than that this remedy is so frequently the similimum in cases of 
ague," I cannot agree with him. I admit that it has a few febrile 
symptoms which appear to be periodical, but the fact that its chief 
indication is periodicity, is a fact from empirical, not pathogenetic, 
data, and cannot be disputed. This fact, and why it is a fact, was 
demonstrated by the experiments of Laveran, Crudelli, and Tomasi, 
who examined the blood of patients suffering from malarious fever, 
and found that when quinine was taken into the system, it destroyed 
the bacillus malariae ; this destruction of the bacillus arrested the 
paroxysms ; but it seems that when it does not destroy them all, then 
the fever may recur every seven or fourteen days. In a late paper 
Laveran says that the bacilli begin to accumulate again in the blood 
within four days, and in seven or fourteen days are in sufficient num- 
ber to cause a relapse. For this reason he advises to begin the use of 



FEVERS. o 

quinine four days after a paroxysm, and its continuance until the time 
of the next one. This plan is not new or original with Laveran, but 
was adopted many years ago by all observant and practical physi- 
cians, though they knew nothing of the bacillus. That they were 
not always successful in preventing a relapse, was due to the fact 
that they gave too much quinine, and caused a condition of the ner- 
vous system and liver which led to the habit above alluded to, — a 
habit of periodical paroxysms simulating ague. I quote from Man- 
quat's summary of the indications for quinine (" Merck's Bulletin," 
March, 1892). In malaria it is efficacious in all types, besides being 
a preventive. Laveran shows that malarial microbes disappear from 
the blood after quinine has been taken for a certain time, and that 
the addition of a minute quantity of a weak solution to malarial 
blood destroys them. He believes the white blood-corpuscles are not 
directly influenced, but enabled more easily to subdue and seize upon 
the micro-organisms rendered torpid or moribund by the drug. If 
given during or just before the onset of an attack, quinine has no 
power to check it, while this may be prevented if taken at a sufficient 
interval beforehand. Baccelli (according to the " British Medical 
Journal ") made intravenous injections of fifteen grains during the 
onset, but during the first six hours could recognize no modification 
in form, number, or movement of the microbes. 

As the largest part of a given dose of quinine is eliminated dur- 
ing the sixth hour after injection — while according to Laveran it is 
during the onset that the microbes are present in blood in gTeatest 
number — the drug should be given at an interval of about six hours 
before an attack. Quinine should be taken eight hours before shiv- 
ering appears in quotidian ague, twelve hours before in tertian, and 
from eighteen to twenty-four hours beforehand in the quartan vari- 
ety. To these figures, however, another hour should be added ; half 
an hour on account of the tendency of the onset of successive attacks 
to be antedated to that extent, and half an hour as allowance for 
imperfect absorption from impaired gastric action. For the last 
reason also, and to obviate its reaction, the required quantity should 
be given in two or three divided doses at half-hour intervals. Two 
doses, eight to ten hours before the expected onset of shivering, 
are almost always effectual. If the result be unsatisfactory, an aper- 
ient should be given. 



6 THE PRACTICE OF MEDICINE. 

Laveran states that no microbes are found in the blood of malarial 
patients after quinine sulphate has been taken for eight days in doses 
of nine to twelve grains, but that if after three or four doses it be 
discontinued the microbes reappear, and a relapse occurs. Upon 
this is based his scheme of treatment, namely : During the first three 
days twelve to fifteen grains of quinine hydrochlorate daily. No 
quinine during the fourth, fifth, sixth, and seventh days. On the 
eighth, ninth, and tenth days, nine to twelve grains. None from the 
eleventh to the fourteenth days. On the fifteenth and sixteenth days, 
nine to twelve grains. None from the seventeenth to the twentieth 
days. On the twenty-first and twenty-second days, nine to twelve 
grains. 

In very severe cases recourse should be had to hypodermic med- 
ication ; fifteen grains of a salt of quinine may be injected sub- 
cutaneously, and repeated after a short interval ; as a rule, twenty 
to thirty grains are sufficient. The injection should be made into 
the deep subcutaneous tissue to avoid complications. The follow- 
ing formula may be used : 

R Quinine sulphate gr. xv. 

Tartaric acid gr. viiss. 

Distilled water drm. iiss. 

Antipyrine greatly enhances the solubility of quinine; fifteen 
grains of quinine hydrochlorate with seven and one-half grains of 
antipyrine will dissolve in one-half fluid drachm of water. When with 
severe depression there is reason to believe no absorption has taken 
place, the solution may be injected into the trachea through the crico- 
thyroid membrane. 

In continued malarial fevers quinine must be given in larger doses. 
Laveran advises twenty to thirty grains daily, nine grains morning, 
fourteen grains evening, till the fever disappears. This nearly always 
happens by the second or third day. If fever persists with four 
days' treatment, it may be assumed to be non-malarial. When the 
temperature falls, nine to twelve grains should be given daily for a 
short time. In malarial cachexia quinine wine (Laroche) may be 
taken with meals, but not fasting or long before food ; otherwise gas- 
tralgia and dyspepsia ensue. 

As a preventive quinine is not effective in smaller doses than two 
to four grains three times a day. It should be given also in all 



FEVERS. 7 

malarial complications and incidental affections (for example, neu- 
ralgia, hemorrhage, pneumonia). 

There are some rules relating to the administration of quinine 
that are important : (1) It does not act favorably if it is given when 
the tongue is coated, foul, and dry ; nor if the bowels are constipated. 
In such cases the liver is generally congested, and the elimination 
of bile not normal. If you desire quinine to act promptly, and not 
to derange the gastric functions, give some chologogue, followed by 
a saline laxative. In most cases one or two grains of blue mass (if 
the patient has not been salivated) acts well. If this is not desir- 
able, give one grain of euonymin, irisin, or one-fourth grain of pod- 
ophyllin in the evening, and the next morning give a glass of rub- 
inat water, or hunyadi-janos ; this will carry off the unhealthy secre- 
tions liberated by the drugs recommended. If these bitter waters are 
objectionable use the citrate of magnesia, or congress water. You may 
go on day after day giving quinine or other remedies for the fever, but 
unless the tongue is clean and moist they will not arrest it. Our 
school have not realized the importance of removing morbid fer- 
menting matters from the bowels in the beginning of malarious 
fevers. 

Ipecac, in certain epidemics of malarial fever, in which the type 
is sometimes remittent, sometimes intermittent, or when the two are 
mixed, seems to be all that is required. When it fails — although 
seemingly indicated by the symptoms, — I think it is because the 
tincture is used. Ipecac does not give up all its virtues to alcohol. 
The trituration of the root is better. Many physicians use a trit- 
uration of nux vomica and ipecac mixed, the lx of each, with good 
results. As in remittent, I like the action of the double remedy — 
ipecac and mercurius dulc. It also acts well alternated with gel- 
semium. 

Eupatorium perf. resembles ipecac in its gastric symptoms, but 
is chiefly indicated by the bone pains, so called. These pains are, 
however, muscular, and resemble those of baptisia and gelsemium. 
The " soreness " of the whole body, of the eyeballs, head, and chest, 
call for it. No remedy is in more common use among the people ; 
and it is probably most effectual, when used in a primative manner 
in infusion. I found that when the tincture or dilutions failed, a 
weak infusion seemed to act promptly. 



8 THE PRACTICE OF MEDICINE. 

Cedron, said to be better adapted to the intermittents of the 
tropics, I have often found useful in the north. It is indicated 
by the exact regularity of the paroxysms, and violent symptoms, 
such as headache, neuralgia, and local pains, which attend the at- 
tacks. In masked ague it is of great value, and in chronic cases 
particularly, where quinine has been used. 

Gelsemium certainly possesses some anti-periodic quality. It dif- 
fers greatly from ipecac and eupatorium, in that the paroxysms are not 
attended by gastric, hepatic, or intestinal derangements. The fever 
has a quick, soft pulse, a scarlet redness of the face, and a soporose 
condition. It is particularly indicated in the quotidian fevers of 
children, and in fevers excited by a chill in hot weather. 

Arsenicum has a high reputation in both schools as a remedy for 
malarial fever, but I never attained with it the success I was led to 
expect by the encomiums heaped upon it ; it never cured for me a 
single typical case of intermittent fever of any variety, i. e., when 
the paroxysms were regular, and consisted of the distinct chills, fever, 
and sweat. This seems to be the experience of others, for Hughes, 
Kippax, and Morse say the more widely the paroxysms vary from 
the typical, the better it is indicated. The chill or sweat may be ab- 
sent, and the apyrexia of uncertain duration. This means that the 
development of the bacilli is irregular, and that the malarial poison 
has a special tendency to attack vital organs. I do not doubt the 
homeopathic ity of arsenic to malarial fevers, or rather to the patho- 
logical condition of the vital fluids and nervous system caused by 
malaria. This is the reason why it is not useful in acute typical 
cases, or when the malaria is engrafted on a cachetic state. But it 
is the chief remedy in typho-malarial fevers, in chronic cases of in- 
termittents, — that persist after several weeks' duration, when the 
general health begins to decline, — or in patients who have contracted 
malaria, have partially recovered after leaving the malarious re- 
gion, but cannot entirely shake off the disease. During our civil 
war it was found useful in the malarial disorders of returned sol- 
diers. The impoverished blood, sallow skin, gastric irritations, and 
tendency to oedema, are the chief indications for it. Good results 
have been obtained from the 3 Ox, and even 20 Ox, according to ap- 
parently trustworthy testimony, but I have not been so fortunate, 
nor have I succeeded so well with the triturations of arsenious acid, 



FEVERS. 9 

as with Fowler's solution, which I have prescribed in the following 
manner : One drop after each meal in chronic cases, or in the mala- 
rial cachexia. If the patient is confined to his house, ten drops in 
half a glass of water, a spoonful every two hours. The lx and higher 
dilutions can be made from this preparation and prescribed on discs. 
In some cases of chronic ague and malarial cachexia, the salts of 
arsenic act admirably. The arseniate of quinine is a favorite with 
many practitioners, when both arsenic and quinine seem indicated ; 
dose, two to three grains of the lx ; arseniate of iron 2x when the 
anaemia is great, the lips and gums bloodless, the feet cedematous, 
and sometimes a general anasarca. Arsenite of strychnine, 2x 
when the spinal and sympathetic nervous systems seem greatly de- 
pressed in vitality, and when a general paresis, with complete ab- 
sence of food assimilation is present. 

Natrum muriaticum comes next to arsenic in usefulness in chronia 
irregular intermittents, with a cachectic condition. It is indicated 
in morning chills (11 to 12 a. m.) followed by violent, hammering, 
frontal headache. Herpes of the lips appears on the third or fifth 
day. Salt is an old and common domestic remedy, but the people 
have a strange way of using it. A saturated solution of common 
salt in vinegar is prepared ; it is taken in doses of one or two tea- 
spoonfuls just before the chill. I have known from observation that 
it is often curative. In an epidemic of intermittent fever that oc- 
curred in 1858, along the south shores of the great lakes, a physi- 
cian in western New York found that the lx trituration of mix 
vomica in salt (instead of sac. lac), cured nearly every case. In 
later epidemics it was not so useful. In " dumb ague " and masked 
intermittents it will cure even in the 3 Ox. This and arsenic are the 
only two drugs that are effective in that dose, so far as I have ob- 
served. 

Eucalyptus globulus seems to me to act like quinine on the ba- 
cilli in the blood of malarial patients. Probably next to corrosive 
sublimate it is the most powerful destroyer of bacterial life now 
known. It is also a powerful disinfectant and antiseptic. The great 
success that attended its use in the hospitals of Australia, California, 
and Algeria proves it to be a rival of quinine, with none of its dele- 
terious effects. In the reports that I collected and published in the 
last edition of " New Remedies," it cursd three-fourths of all cases 



10 THE PRACTICE OF MEDICINE. 

of quotidian, tertian, or remittent malarial fevers. In those cases 
that resisted the drug, while the periodic paroxysm remained, it was 
much milder ; the tongue cleaned, the secretions became healthy, and 
the remaining symptoms were readily removed by small doses of 
quinine. The excessive colliquative night-sweats during the apy- 
rexia also ceased. The dose usually prescribed is one drachm of the 
tincture every three or four hours, or three times a day, during the 
apyrexia and paroxysm. I have tested its value in Michigan, also in 
Chicago, where malarial fevers do not originate, but are contracted in 
the suburban regions, and I find that less than five drops of the mother 
tincture every two hours does not suffice, and larger doses are often 
required. It is said on high medical authority that when the trees 
are planted on the malarial lands of Algeria, France, Italy, and Mex- 
ico, their influence prevents the fever of those regions. In the United 
States, except southern California, New Mexico and southern Texas, 
the eucalyptus will not grow north of 28° ; even in Florida it cannot 
resist the frosts that occur there every winter north of Tampa. 

If my readers desire to consult authorities relating to the many 
remedies recommended, they will find the theoretical indications 
enumerated in the works of Boenninghausen, Allen, and Kippax. 

Prophylaxis of malaria. Eesidents and travellers in malarious 
districts have taken quinine and eucalyptus with apparent benefit. 
African explorers have all used quinine, and the results were uni- 
formly good. They found that six grains a day were sufficient. 

A recent letter from a Scotch mission near Lake Nyasa gives the 
information that " ten grains of quinine with five drops of eucalyptol, 
taken every third day during a journey by river, prevented any attack 
of fever during the journey or since." This is worthy a trial by 
physicians who practice in malarial regions, and who are exposed to 
infection. 

II.— REMITTENT FEVER. 

A continued fever with daily exacerbations due to the presence 
of the bacillus malarise in the blood. It is ushered in, generally, by 
a chill, — followed by frontal headache, nausea, vomiting, a foul 
tongue, and signs of biliary derangement ; there may be catarrhal 
or bilious diarrhoea or constipation. At first, there is a decided re- 
mission in the morning, when the temperature is about normal, but 
near the seventh day the remissions become less, and a typhoid state 



FEVERS. 11 

seems to obtain. The average duration is two weeks. It may change 
on the seventh day to a quotidian intermittent. 

The treatment of Remittent Malarial Fever should be pursued 
on altogether different lines. Quinine should never be used, nor 
cinchona, unless there comes a distinct intermission, when the tem- 
perature is normal ; it will aggravate the fever, and precipitate the 
typhoid state. In the beginning of a remission, gelsemium is gener- 
ally indicated, and, if indicated, will sometimes terminate the fever 
in a few days ; the bacillus in this fever is not so virulent as in the 
intermittent or pernicious type. Gelsemium should be given in 
appreciable doses of the tincture, but not enough to cause pathogen- 
etic symptoms ; usually one to three drops every hour or two is suf- 
ficient. If there be much or any marked gastric or bilious disturb- 
ance, murcurius dulcis and ipecac are my favorite remedies, given in 
combination, two or three grains of the lx trituration every hour. 
A tablet of that dose is an elegant preparation ; under the use of 
it the tongue becomes clean, the bowels move gently, and the remis- 
sions glide gradually into intermissions. When this occurs quinine, 
in one-half or one grain doses every hour, should be given only 
during the apyrexia. At the access of the fever, return to gelsemium 
until perspiration appears ; sometimes this drug will suffice, for it 
seems to have a certain antiperiodic power ; it will often cure an 
intermittent neuralgia unaided. 

Eupatorium perfoliatum is often specific when there is violent 
bone-pain, soreness of the body, occipital headache, bilious vomiting 
and diarrhoea, and fullness and tenderness of the hepatic region ; it 
will cure when the remission is almost an intermission ; the most effi- 
cient dose is five to ten drops of the tincture, every hour or two. 

Bryonia and baptisia are useful during the second week, when 
the fever is more continuous, and the symptoms are more typhoidal. 

There is a tendency in a remittent, ending on the seventh or four- 
teenth day, to recur in seven or fourteen days after. Here quinine 
is indicated ; two grains three times a day, or the arsenite of quinine, 
a grain of the lx three times a day, until the critical day is passed. 

III.— PERNICIOUS MALARIAL FEVER. 
This is another fever caused by the bacillus malarise ; it is malig- 
nant, and characterized by dangerous local complications. Impor- 



12 THE PRACTICE OF MEDICINE, 

tant organs are attacked, and their functional life destroyed, or 
serious pathological changes caused in them. It may be remittent 
or intermittent, generally the latter. The pernicious symptoms 
usually appear with the second or third paroxysm. It may assume 
several forms ; the varieties have been named comatose, delirious, 
choleraic, algid, colliquitive, icteric, and another, which I shall call 
convulsive ; this latter generally occurs in children. This fever 
most frequently occurs in the tropics and the Gulf States. Dr. 
Drake says it occurs along the southern shore of Lake Michigan, 
from Chicago to St. Joseph, also on Lake St. Clair and Lake Erie : 
in fact, all the south shores of Lakes Huron, Erie, and Ontario. 
Between 1850 and 1860, the south half of Michigan was infested 
by this dangerous fever, but I learn that all the country mentioned 
by Dr. Drake is now practically free from any but the mildest 
form of malarial fever. In southern Michigan, where it was most 
prevalent up to 1880, the pernicious form is actually unknown. 
Its onset may be as mild as any common form of ague, but on the 
second or third attack, it may suddenly assume a dangerous char- 
acter. Whenever my patients had cold fingers or toes during the 
height of the hot stage, I could safely predict that the next parox- 
ysm would be dangerous. 

Treatment. — It is a mistake, most prevalent in the Homeopathic 
school, that the different varieties above named need different treat- 
ment ; the same remedy is indicated in the comatose as in the chol- 
eraic form, because the same cause is at the bottom of the malady. 
The remedy must be directed against the cause, and not altogether 
against its symptomatic manifestations. I would advise my readers 
to study the differential diagnoses of this disease, that they may not 
treat it as a cholera morbus, an apoplexy, or a meningitis. (See 
Kippax, Arndt, and Loomis.) There is no time to be lost, if you 
are called to a patient who has had two paroxysms of ague, the sec- 
ond one having symptoms of collapse, or either of the above varie- 
ties. A delay of an hour in the use of the proper remedy may 
mean life or death. In many cases, the stomach or the rectum will 
not tolerate the presence of the necessary remedy ; here is where 
the hypodermatic method shows its unequaled value. During my 
practice in a malarial district, 1850 to 1860, the hypodermic 
syringe was practically unknown west of New York City ; and I 



FEVERS. 13 

had to rely on the usual methods of administering medicines. I 
soon found that such a condition of low vitality as obtains in perni- 
cious fever destroyed the power of absorbing medicine, and that 
stimulation by the stomach or rectum was almost nil. I lost sev- 
eral patients under the use of attenuated remedies, and I lost some 
under the use of moderate doses of quinine. It occurred to me 
that if I could stimulate the circulation temporarily at the time of 
giving the drug, it would facilitate absorption. Of course, the time 
to arrest the dangerous paroxysm is during the apyrexia, and the 
three hours preceding is the best time. I therefore adopted the 
following treatment when I had to deal with an impending perni- 
cious paroxysm. Beginning about three hours before the paroxysm, 
I gave five grains of quinine in hot coffee, with the addition of one 
to five drops of a one per cent solution of glonoine (nitroglycerine) . 
This was repeated every hour, and generally prevented the paroxysm. 
I believe 1 was the first to use glonoine for its stimulating power. 
Brandy or whisky seemed to have no more effect than water in such 
cases, especially during the period of collapse. I tried atropine, 
but it was not satisfactory ; the nitrite of soda in three to five grain 
doses would be better, as its action is more lasting. The administra- 
tion of quinine, especially the bi-sulphate of quinine, combined with 
glonoine or nitrite of soda, in the following formula, injected into 
the arm or thigh : 

1^ Quiniuse bisulphatis gr. 5 

Glonoinae (1 per cent so.) gtt. 2 

Aquae dest drm. ss. 

In the dangerous state which obtains during the paroxysm, if we 
fail to prevent it, or are not called in time, the remedies must be de- 
lected in accordance with the symptoms. I do not think quinine 
should be used during the paroxysm, except as a stimulant ; when 
given before the paroxysm, we expect it to act on the baccilli in the 
blood, arresting their vitality ; when we use it during the paroxysm 
we use it for its stimulating qualities. Fifteen grains every hour 
during a paroxysm might cause death, or a dangerous aggravation. 
Forty to sixty grains have had this effect in health. We should not 
inject more than two or three grains, and this should be combined 
with glonoine if the heart's action is very feeble ; with atropine, if 
there is colliquative sweating; with morphine and atropine in 



14 THE PRACTICE OF MEDICINE. 

choleraic discharges ; with opium or hyoscine, in the delirious or 
comotose variety ; with euonymine in the icteric variety. Quinine 
should not be used in the convulsive variety, unless combined with 
veratrum viride, gelsemium, or passiflora, and then only before 
the paroxysm, which usually occurs during the acme of the fever. 
When you have been called during a paroxysm, and have brought 
the patient " out of the depths," you have to prepare to ward off 
another paroxysm ; it is the third that kills. If the patient's tongue 
is foul, the skin icteric, the bowels constipated, give ten grains of 
euonymine lx trituration, or mercurius dulcis lx, or leptandrin 
lx, in the same dose, repeated every two hours until bilious evac- 
uations occur. Quinine does not act well when the patient is in 
that condition ; it will aggravate the biliousness, and when the toxic 
elements of bile are in the blood, the paroxysms of any kind of 
ague are more difficult to control. Begin three or four hours before 
the time of the paroxysm, and use the quinine as directed. 



IV.— TYPHO-MALARIAL FEVER. 

This I would define, not as a distinct entity, but as a Typhoid 
mixed with a Malarial Fever. Both can co-exist in the same organism. 
During the first ten years of my practice in one of the most malarial 
spots in the West, I had frequent occasion to treat this type of fever. 
The village had no sewerage, and the privies in town and coun- 
try were nearly always in close proximity to the wells or springs. 
Typhoid fevers were common in the late autumn or winter months, 
not so common in summer ; but when they did occur in that season, 
many cases were complicated with the various forms of intermittent, 
remittent, and pernicious malarial fevers. The most watchful care 
is necessary in such cases to prevent a fatal termination any time 
during the progress of the malady. Often we have to combat the 
combined toxic influences of both poisons at the same critical period. 
After several years' disappointing and often sad experience with the 
ordinary remedies then recommended in our text books, I had to 
adopt an original treatment of my own. If, at the outset of the 
malady, both the typhoid and malarial elements were present, I began 
with gelsemium or eupatorium, if their well-known symptomatic indi- 
cations were present. Later on, baptisia and eucalyptus would be 



FEVERS. 15 

indicated. If the tertian type showed itself, arsenic was found to be 
the best remedy ; if the quotidian form appeared, quinine had to be 
used. During the apyrexia, or almost complete remission in the 
morning, one or two grains were given every hour till the fever 
increased, when gelsemium or baptisia was given until the next morn- 
ing. This treatment generally subdued the malarial element for 
seven days, when it sometimes returned. Often eucalyptus alone 
given in ten-drop doses subdued all the febrile symptoms. Had I 
known of Dr. Yoe's " Chlorine water and quinine mixture," I should 
have used it. My success with this treatment was much better 
than was that of my colleagues who adopted the routine '•regular'* 
treatment, or those of my own school who trusted to the symptomatic 
treatment with highly attenuated medicines. To prevent relapses 
a change of residence for a few months is often necessary. 



TYPHUS FEVER. 

Definition. — Gould ( '•• Medical Dictionary ") defines this k - An 
epidemic, contagious, exanthamatous fever, due to a specific but not 
isolated germ, characterized by a peculiar petechial eruption, and 
depression of the vital powers, without lesion."' Kippax (" Lectures 
on Fevers ") gives a very complete and interesting history of this 
disease. It is rarely seen in this country, is always imported, being 
brought here by immigrants from Ireland, Italy, Russia, and a few 
other countries. I have never seen a case, and will not venture to 
advise any treatment based on actual experience. 

The treatment cannot differ to any extent from that of typhoid 
fever. Xot having any intestinal lesion or local foci for the dis- 
semination of the unknown germ, or bacillus, there is no need of 
intestinal antisepsis. The constipation which attends this disease 
should not be allowed to persist too long. Foecal matter accumu- 
lated in the bowels when the temperature of the body is high will 
generate ptomaines. Without irritating the bowels, they should be 
kept free from fceeal matter. 

I refer the reader to Arndt's ''System of Medicine." and Dr. 
Kippax's exhaustive chapter in his ''Lectures on Fevers." 



16 THE PRACTICE OF MEDICINE. 

RELAPSING FEVER. 

Definition. — A peculiar contagious fever ; epidemic ; due to a 
specific poison ; occurring during famine ; not a native of this coun- 
try, but like typhus has its habitat in the same countries. It has 
occurred occasionally in this country, but only when imported. No 
epidemic has occurred in the western States, but I have seen a few 
isolated cases in Chicago, undoubtedly contracted by exposure to 
newly arrived filthy immigrants. 

The same treatment, diet, and hygiene recommended for typhoid 
will be suitable for this. I again refer the reader to Arndt's " Sys- 
tem of Practice " and Kippax's " Lectures on Fevers." 



DENGUE FEVER. 

Definition. — An acute febrile affection of short duration, which 
appears as an epidemic in hot climates. It is due to an unknown, 
external, specific cause (probably a bacillus), and is characterized 
by two distinct and essentially different febrile paroxysms, separated 
by a remission. It is attended by decided rheumatic pain, with 
soreness and stiffness of the muscles, and occasionally by a cutaneous 
efflorescence like that of scarlet fever. It resembles some of the 
varieties of grippe, which often occur without any influenzal symp- 
toms. The lymphatic glands, inguinal and axillary, are sometimes 
inflamed and may even suppurate. Relapses may occur. The se- 
quelce are similar to those of grippe. 

Treatment. — Kippax recommends belladonna, bryonia, eupat- 
perf , gelsemium, hyoscyamus, pulsatilla, and rhus ven. Dr. Falligant 
of Savannah, who has had a large experience in this disease, recom- 
mends aconite, bryonia, arsenicum, mercurius, ferrum, secale, and 
sulphuric acid. I have never treated this fever, but theoretically I 
would advise, in addition to the above, salicylate of soda, phenace- 
tine, acetanelid, manaca, cimicifuga, and the hot pack. Hughes ad- 
vises cactus and jaborandi. The regular school recommends bella- 
donna very highly, which is singular, for belladonna is quite homeo- 
pathic to the symptoms of the disease. They advise the bromides 
for children, to combat the tendency to convulsions, and, of course, 
quinine, although they are not sanguine as to its curative powers. 



FEVERS. 17 



TYPHOID FEVER. 



Definition. — A continued fever due to a specific poison, the ba- 
cillus typhosus, found in certain forms of animal matter. When 
this bacillus is taken into the system in drinking water or milk, 
or inhaled from an infected atmosphere, a fever is caused which is 
characterized by a gradual approach, followed by malaise, anorexia, 
dull headache, epistaxis, and bronchial cough, a dry and red or 
brown tongue, diarrhoea, with pea soup or ochre-colored dis- 
charges, tympanites and abdominal tenderness, especially in the 
right iliac fossa ; rose-colored spots after the seventh day, appearing 
in successive crops ; stupor and delirium, prostration, and slow con- 
valescence. The morbid changes are chiefly in the lower part of the 
ileum, and consist of a necrotic inflammatory infiltration of the folli- 
cular structures and neighboring parts, commonly called Peyer's 
patches. This fever is also known as nervous fever, enteric fever, 
infantile remittent fever, gastric fever, etc. The temperature is 
characteristic ; it is usually one degree higher each successive morn- 
ing; 99° to 103° in the morning and 100° to 104° in evening, till 
the seventh day. The second week it remains nearly stationary, 
with slight evening exacerbations. The third week it declines in 
about the same ratio as it increased the first week. The temperature 
may not become normal till the twenty-eighth or thirty-fifth day. 
Cases that run their course with but little or no rise of temperature 
are called "walking typhoid," because the patient keeps up and 
sometimes attends to his daily business. 

The complications are congestion of the lungs, intestinal hemor- 
rhage, perforation of the bowels, or fatal peritonitis. The sequelae 
are dropsy, phegmasia dolens, paralysis, dysentery, periostitis, ab- 
scesses, and mental hebetude. 

Treatment. — It is the physician's duty, not only to treat the pa- 
tient, but to take measures to prevent the spread of the disease. So 
soon as he is satisfied that the disease is typhoid, the cause should 
be sought after and found, if possible. It is necesssary to boil all 
the water and milk used by the patient, even when the infection can- 
not be traced to those fluids. The sewerage of the house must be 
examined and, if defective in the slightest degree, repaired. The 
dejections of the patient must be thoroughly disinfected before they 



18 THE PRACTICE OF MEDICINE. 

are disposed of, by covering them with a five per cent solution of 
carbolic acid, or a two per cent solution of chloride of zinc, or a one 
per cent solution of lysol or creolin. In the country, when the dis- 
ease is prevalent, the disinfected discharges should be emptied into 
trenches and carefully covered over, and these trenches should be 
far away from wells or springs. The patient's body-clothes should 
be thrown into one of the above-named solutions for disinfection, 
and afterwards boiled. If the well, spring, or hydrant water is be- 
lieved to be infected, it should not be used for washing cooking- 
dishes until after it has been boiled. In the management of the 
fever, we must remember that it is purely asthenic. The vital forces 
are taxed to the utmost to contend against the poison. Depressing 
agents must be avoided, therefore, and physical exertion reduced to 
its lowest limit. The use of antipyretic drugs, or the application of 
extreme cold, should not be thought of. Hyperpyrexia, once such 
a bugbear, is not now feared so much as formerly. Many patients 
have a temperature of 104° to 106° for weeks, yet make good recov- 
eries. The reduction of temperature by means of antipyrin and its 
analogues has no permanent benefit ; on the contrary, such drugs 
weaken the muscular structure of the heart, an en ecu to be avoided. 
They do not destroy the bacilli or their poisonous products, but on 
the contrary, according to Drs. Roque and Wiel, of Paris, cases of 
typhoid fever treated with antipyrin and other similar drugs abso- 
lutely prevent the elimination of toxines. They also state that in 
cases treated with cold baths, the elimination of toxines by the kid- 
neys is enormous during the whole course of the disease. Regard- 
ing the use of cold water, Dr. Germain See, of Paris, decides that 
water at a temperature of 90° to 97° F. acts better than water at a 
low temperature. My personal experience is that sponging and 
compresses of warm water give more relief, and conduce more to a 
modification of the fever, than does cold water. I believe that the 
application of ice or ice-water to the head, or to the bowels in tym- 
panites is a very reprehensible proceeding ; it is not the heat that 
kills the fever patient, but the toxic products of the bacillus. 

Ventilation of the sick room should be thorough, and the temper- 
ature kept between 60° and 70° F. At the outset of the fever, or 
before, if we can recognize it, I believe the administration of bap- 
tisia will sometimes abort the disease unless the secretions are greatly 



FEVERS. 19 

infected. If during the prodromic stage the patient's bowels have 
been confined, they should be unloaded thoroughly, but in the gen- 
tlest manner. I prefer to do this with an injection of two quarts of 
hot water, containing one drachm of boric acid. A mild laxative 
like magnesia, or syrup of rhubarb, can do no harm, but a strong 
irritating purge aggravates the disease, and especially the local in- 
testinal lesion. The medicines used in the treatment may be di- 
vided into constitutional, antiseptic, and palliative. A constitutional 
remedy must be one capable of causing symptoms similar in appear- 
ance and duration, and local lesions similar to those occurring in 
this fever. The antiseptic remedies are those which, when taken 
into the stomach, pass into the intestines, and either destroy the 
bacilli or render innocuous their toxic products. Palliative reme- 
dies are required to remove or ameliorate transient symptoms which 
arise during the course of the fever. Some of our text-books enu- 
merate fifty or sixty remedies to be used in typhoid fever. This is 
confusing and absurd. This fever being a self-limited disease, all 
we can do is to modify its virulence ; evanescent symptoms will come 
and go, whether we use medicines or not. The expectant treatment 
adopted in the hospitals of London and Paris, shows a much lower 
death-rate than the drug treatment of the dominant school ; under 
the homeopathic treatment the death-rate is a little better. There 
are but few constitutional remedies for typhoid fever. Arsenic 
stands at the head of the list ; whatever other remedies are used, this 
should be given all through the course of the disease unless the attack 
is a very mild one. Four doses a day, of the 2x dilution of arsen- 
ite of soda, or the 2x trituration of arsenic acid, or arsenite of 
strychinia, will greatly modify the disease. 

Baptisia ranks next, especially during the first week, when the 
temperature is highest, and we find the characteristic aching and 
soreness of the whole body, the darkly-flushed face, and the f oeter of 
the breath, sweat, and evacuations. 

Veratrum viride is rarely needed, for true typhoids do not have 
the hard, large, quick pulse which calls for it. 

Gelsemium has been of value in my hands in some cases when 
there was an evident miasmatic or catarrhal complication. 

Bryonia and rhus toxicodendron, successfully used by Hahnemann 
in epidemics of typhoid in Germany, are not as well adapted to 



20 THE PRACTICE OF MEDICINE. 

typhoids in this country. The rheumatic complications which indi- 
cate them are rarely present. Bryonia resembles baptisia more than 
it does rhus, and is indicated when there are bilious complications. 
Rhus is to be preferred when the patient lives in a low and damp 
locality. 

Belladonna, hyosciamus, agaricus, and stramonium are useful 
when there is unusual cerebral excitement. 

The mineral acids cannot be dispensed with. Phosphoric acid 
when the mental and physical forces are at a low ebb, with hebe- 
tude, stupor, and paresis. Nitric acid, when ulceration of the intes- 
tines apparently exists, and there is tenderness of the bowels, ulcer- 
ation of the mouth, and slimy, bloody evacuations. Muriatic acid 
compares with arsenicum, but is especially useful in the last weeks 
of the disease, when there is decomposition of the vital fluids, dry 
dark-colored tongue, coated or not, difficult speech, and continuous, 
muttering stupor. When this acid is indicated, beef tea is generally 
adapted to the case, and I find that the acid acts best when added 
to the beef tea in the proportion of a teaspoonful of the dilute acid 
to a pint, and a tablespoonful given every hour or two. Sulphuric 
acid is only useful in black persistent hemorrhages, with ecchymoses 
or purpura. 

Turpentine, eucalyptol, and oleum erigeron, are indispensable in 
all severe cases ; a red, dry, glazed tongue calls for their use. They 
prevent fermentation and the distressing formation of gases present 
in tympanites. They are powerful antiseptics, and probably destruc- 
tive to the bacilli. Turpentine and erigeron are the best remedies 
for hemorrhages, and all favor the healing processes in the intestinal 
ulcers. But they must be administered in a proper manner, or they 
are valueless. When given by the mouth they should be prescribed 
in an emulsion containing three to five drops in each dose of a tea- 
spoonful, and repeated every two or four hours until the threatening 
symptoms are better. Sometimes, as in tympanites, the emulsion 
with yolk of egg should be given in an enema, in double or treble 
the dose, mixed with hot boiled water or milk, and thrown high up 
into the colon. In several cases I used the " sanitas oil " with good 
results ; the oils of peppermint and gaultheria, and possibly sassa- 
fras, could be used with confidence when the others are not obtain- 
able, and in the same dose. 



FEVEMS. 21 

Nux- vomica (strychnia), ignatia, and arnica, are indicated when 
the muscular weakness, with or without irritability, is very great, the 
eerebro-spinal system is profoundly depressed, and the patient lies 
as if paralyzed, motionless, or with involuntary jactitations. I prefer- 
in such cases the phosphate or nitrate of strychnia, in doses of one- 
fiftieth to one-hundredth grain. In two cases the one-thirtieth grain 
every six hours had a potent curative influence when all hope had 
been abandoned by the attending physician. In many cases tinc- 
ture of arnica root, in two-drop doses every hour, acted promptly 
when all the dejections were involuntary, and the patient could not 
be aroused from his lethargy. 

Muriate of hydrastia (white alkaloid) acts similarly to strychnia. 
and is indicated when a general catarrhal state of the bronchia, 
fauces, and stomach obtains. My favorite formula is as follows : 

R Hydrastia mur gr. ii. 

Dilute muriatic acid dr. i. 

Distilled water 02. iv. 



Give a teaspoonful every four hours. 

Digitalis and strophanthus should not be forgotten when the 
heart becomes weak and flagging, and when slight movement causes 
it to beat rapidly, or to intermit. In such cases it is dangerous to 
allow the patient to turn over quickly, to sit, or to stand. 

This tendency to heart failure often extends into convalescence ; 
and when I observe it, I prescribe digitalis or strophanthus (two to 
four drops of the tincture) every two or four hours. Each acts bet- 
ter when alternated with strychnia. The former acts directly on the 
heart muscle and inter-cardiac ganglia ; strychnia indirectly through 
the spinal cord. (Cactus is often indicated.) 

Mercury and its preparations I rarely use in typhoid, and never 
in appreciable doses. Merc. dulc. is sometimes useful when, during 
the first stages, the tongue is flabby and foul, with edges showing the 
pressure of the teeth, and the discharges are green or black. Merc. 
corros. does good service when there appears to be inflammation of 
the peritoneum ; it rivals arsenic and nitric acid when there is ulcer- 
ation of Peyer's patches. Opium will often rouse the patient from 
the profoundest coma : I have known a few doses of one-half or one- 
fourth drop of the tincture to have this effect. Per contra. I have 
found that hyoscine, an alkaloid of hyoscyamus. acted much better 



22 THE PRACTICE OF MEDICINE. 

than the latter when the insomnia at night was persistent. Hyoscine 
acts equally well if the patient has noisy delirium, with illusions or 
hallucinations. One or two doses of the one-two-hundredth of a grain, 
or even the one-five-hundredth of a grain, acts with magical effect. 

Phosphorus is often better than arsenic, when to the arsenical 
symptoms there is added a congestion or inflammation of the lungs. 
In the so-called " typhoid pneumonia " it is the sheet anchor ; but 
it may sometimes need the aid of sanguinaria, or tartar emetic, or, 
better still, the arsenite of antimony. 

Zincum, especially the picrate or phosphide, is a great aid to us 
when the mental hebetude is profound, and the patient seems almost 
idiotic. This condition often occurs during tedious convalescence, 
when the patient has not been sufficiently nourished, or when too 
much alcoholic stimulant has been given. Ferrum muriaticum is 
very useful in the anaemia during convalescence. 

It may be observed with surprise, perhaps, that I have made no 
mention of cinchona among the remedies. I have omitted it because 
I do not consider it of any value in small doses, and because in ma- 
terial doses it rarely agrees with the patient. Its alkaloid quinine is 
rarely indicated, although there are two conditions in which it may 
be useful, — (1) when during the last week, or during convalescence, 
the debility assumes the following phase : the patient, when asleep, 
sweats profusely, especially on the upper half of his body, has ring- 
ing in the ears, and is deaf ; (2) when the fever occurs in a mias- 
matic locality, and is of an intermittent character, instead of typical. 
This condition, with or without the symptoms noted under the first, 
calls for quinine. I prefer the bisulphate, or muriate, always pre- 
scribed in a watery solution, with the addition of a little sulphuric 
or muriatic acid, as the symptoms may indicate. One or two grains 
at a dose in each teaspoonful of the solution, given every four hours, 
is sufficient. The frightful abuse of this drug in typhoid fever, 
especially by country practitioners, is greatly to be deplored ; it com- 
plicates, and renders dangerous, cases which, if left alone or treated 
only with appropriate remedies, would surely recover. 

Salicin, the alkaloid of salix alba (willow), has an advantage over 
quinine in that it is rarely toxic, even in very large doses ; it has all 
the tonic properties of quinine, and is nearly equal to it in antiperi- 
odic powers. A late authority says : " Besides its antifebrile action, 



FEVERS. 23 

it has a marked effect on the whole nervous system, and when admin- 
istered in doses of twenty grains every hour for ten or twelve hours 
consecutively, the blood becomes so saturated with it as to prevent 
the multiplication of all sorts of germs or microbes." When used in 
typhoid fever the dose need not exceed two or three grains every two 
or three hours. When thus administered, I have seen it greatly 
modify the fever and other toxic symptoms. 

Eucalyptus globulus has antiseptic and disinfecting powers not 
exceeded by any other drug in the vegetable kingdom. Its active 
principle is eucalyptol. If I were confined to any one remedy in 
the treatment of typhoid, I would select this. When taken into the 
alimentary canal, it mixes with and disinfects its contents, destroys 
or prevents the multiplication of bacilli, and neutralizes their toxic 
products. It is taken up by the absorbents, and is excreted by the 
kidneys, skin, and bronchiae. In Australia, the home of the drug, 
it has been thoroughly* tested in the fever hospitals and in private 
pract lV _,, and is pronounced superior to all other remedies. In 
typhoid and typhus, the temperature was reduced to 100° F. or 99° 
E.; the discharges from the bowels lost their foetor, the cough was 
benefitted, and the convalescence was more rapid. The death-rate 
was the lowest ever known in that disease. The dose was thirty to 
sixty drops, every three hours. I have treated many cases with 
eucalyptus alone with very satisfactory results, though smaller doses 
were used — five to ten drops every three or four hours. 

Treatment by Antisepsis. — Since the general adoption of the 
germ theory of disease, physicians have been looking for some safe 
drug that would act as an intestinal antiseptic without depressing 
the vitality of the patient, or acting as a local irritant. No agent 
has yet been discovered that will completely destroy the bacillus 
and its toxic products, ptomaines, in the intestines without injury to 
the patient. But if we can artificially destroy the baccillus, we 
shall lessen the production of ptomaines, and thus curb the virulence 
of the fever. To a certain extent, I believe this can be accomplished, 
and I have tested several drugs with results that were not discour- 
aging. 

Napthaline, which I first tried in several cases, did not give as 
good results as eucalyptus. Salol gave better results ; the dejections 
became quite inodorous, and the temperature was modified. These 



24 THE PRACTICE OF MEDICINE. 

drugs were given in capsules of three grains every four hours. They 
do not interfere with the action of baptisia, arsenic, or the mineral 
acids. Dr. Yeo, of London, praises free chlorine as the best agent for 
the antiseptic treatment of typhoid fever. It is prepared as follows : 
Chlorine is generated in a bottle by pouring pure hydrochloric acid 
(forty drops) upon one-half drachm of chlorate of potassium ; after 
two or three hours a little water is added to make the whole meas- 
ure ten fluid ounces. In this manner, the author says, " we obtain an 
almost pure solution of chlorine." According to the severity of the 
disease, one or two teaspoonfuls are given three or four times a day ; 
most favorable results are claimed. Dr. Yeo adds frequently thirty 
grains of muriate of quinine to this mixture, but the chlorine had 
better be given alone. 

Hydronaphthol,beta naphthol, and benzo naphthol, have been used 
by Dr. M. Clark of London. The last drug prevents the develop- 
ment of the typhoid bacillus when used in the proportion of one to 
ten thousand. It is tolerated perfectly, even in children, in doses of 
ten to thirty grains repeated several times a day. Dr. Clark claims 
that the results were : (1) reduction of the average of the fever ; (2) 
less offensive stools ; (3) early cleansing of the tongue and less dry- 
ness of the mouth ; (4) absence of albuminuria ; (5) convalescence 
more rapid, and the strength conserved ; (6) less risk of the propa- 
gation of the disease ; (7) diminished tendency to secondary compli- 
cations. It would seem from the above that intestinal antisepsis 
may some day be safely accomplished, and that we may add to our 
resources in the treatment of typhoid. 

The advocates of intestinal antisepsis, however, meet with oppo- 
sition from high sources. I am inclined to side with Dr. Simon 
Baruch, editor of the " Dietetic Gazette," who, in that journal's issue 
for November, 1892, writes as follows : 

" The brilliant achievements of modern surgery, based upon the 
recognition of a bacterial etiology, have borne results in internal 
medicine which, sooner or later, must bring the true physician to 
grief. Since antiseptics have led to such remarkable triumphs in 
the open field of surgery, why should not the same results be achieved 
in the hidden field of internal diseases, which have also been traced 
to micro-organisms ? This appeared to be a legitimate corollary. 
And yet it has already proved so fallacious that it is time to call a 



FEVERS. 25 

halt in the eager pursuit of parasiticides that are supposed to pursue 
the microbe to its innermost hiding place, and destroy its vitality ere 
it jeopardizes life and health. A little reflection must demonstrate 
that the treatment of infectious diseases by antiseptics is one of the 
will-o'-the-wisps of the present progressive era. 

" First : It is not probable that the action of parasiticides, as dem- 
onstrated in the test tube, may be relied upon in the remote recesses 
of the human body. Conditions exist here which must modify or 
neutralize their effect. The various acid and alkaline fluids, through 
which the antiparasitic remedy must pass, the osmotic conditions to 
which it may thus be subjected, its possible entanglement in mucous 
or purulent fluids, — all these operate more or less antagonistically 
against the precision which is attainable in the laboratory. 

" Second : A large proportion of the organisms to which are at- 
tributed baneful results in many diseases, are usually not accessible 
to the action of parasiticides. In typhoid fever, for instance, a dis- 
ease in which superficial reasoning would direct their attack to the 
main lesions in the intestinal tract, a deeper study would develop the 
fact that ere the disease is diagnosed, these organisms have already 
passed into the lymphatic glands, the spleen, and even into the small 
lenticular spots on the skin, which are the chief characteristics of 
the disease. How naphthaline, or salicylate of soda, or salol, or 
sulpho-carbonate of zinc, or bismuth, is to enter the blood and pur- 
sue these enemies into their very innermost lairs, l passeth the under- 
standing.' 

" Third : Even if this were possible, the experiments of Koch 
and others have shown conclusively that certain concentrations are 
required for certain bacteria. No sane man would venture to apply 
these concentrated solutions of antiseptics to any large surface of the 
body, lest their local or general effect resulting from absorption pro- 
duce the most dire consequences. Nor would it be possible to main- 
tain the integrity of the blood in which they are supposed to be dis- 
solved. 

" Fourth : Even if this were possible, we are confronted with the 
fact that it is not the micro-organisms themselves which are to be 
dreaded, but the ptomaines and toxin es, whose effect is so destruc- 
tive to the animal economy. Since the organisms are already firmly 
entrenched in the latter, and have already begun their productive 



26 THE PRACTICE OF MEDICINE. 

career when the physician's aid is invoked, the attempt to destroy 
them would be futile. 

"Arguing upon these briefly-stated premises, it may be assumed 
that the internal administration of antiseptics in infectious diseases 
is not so promising as many enthusiasts would have us believe. This 
pessimistic view may be met by the clinical demonstration of the 
value of the antiparasitic treatment in some diseases. Reports are 
constantly published of favorable results which are ascribed to anti- 
septics. Among these we may take as an illustration the applica- 
tion of sulpho-carbolate zinc in typhoid fever, which is advocated by 
capable and intelligent physicians. As it is impossible to formulate 
definitely the result of any treatment in a self-limited disease, the 
simple clinical results cannot be accepted unless the rationale of its 
attainments appeals to our reason. The destructive effect of sulpho- 
carbolate of zinc upon the bacillus of Eberth has never been demon- 
strated, even in the laboratory. Were this possible it would surely 
have been done. As has been well said in a recent able paper on 
this subject by Dr. J. N. Berry, in the 'New England Medical 
Monthly ': 

" 4 That germicides, as such, have at times curative properties is 
undisputed. We can understand how carbolic or salicylic acids ar- 
rest fermentation, but to be convinced that five-grain doses of salol 
or sulpho-carbolate of zinc, both feeble germicides and hardly suffi- 
cient to sterilize an external ulcer, after running the gauntlet of the 
digestive fluids, including an acid and an alkaline secretion, and after 
passing over twelve or more feet of intestine and many square feet of 
mucous surface, and escaping absorption, will find their way to the 
lower third of the small intestine, and promptly disinfect the secre- 
tions of twenty or more Peyer's patches, demands that truly sublime 
confidence in the efficacy of drugs which we have not yet been able 
to acquire.' 

"If the disinfection of the intestinal contents be the object of 
the so-called antiseptic treatment of typhoid fever, even this object 
must fail of accomplishment by the usual remedies. In a disease 
like the summer diarrhoea of infants, in which bacteria have been 
shown to play an important role, and in which they are really more 
accessible than in any other disease, it must be accomplished by 
attacking these organisms. But surely no rational therapy would 



FEVERS. 27 

countenance the pouring of parasiticidal solutions in the gastroin- 
testinal tract. Recognizing the fact that food containing bacilli is 
one of the chief etiological factors, its sterilization is resorted to as 
a prophylactic agent. Should bacteria, however, accumulate in the 
intestinal canal, they may be attacked by irrigation. 

" Inasmuch as the lesions are usually found in the large intestines, 
this may be done with some show of success. But clinical expe- 
rience has demonstrated here, as it has so often done elsewhere, that 
the more simply we treat these conditions, the greater will be the 
success. Just as boiling water has proven to be the best disinfect- 
ing agent for the surgeon's instruments, and boiled water the best 
disinfecting agent for fresh wounds (Shimmelbusch), so has the 
psedriatric physician discovered that plain boiled water is the most 
useful agent for intestinal irrigation, after adapting it to the sensi- 
tive mucous membrane by the addition of a little chloride of sodium. 
Just as in the pursuit of surgical asepsis, the mechanical element of 
the agent is regarded as more important than the chemical, so does 
the intelligent physician regard the simple washing of the diseased 
surfaces in the bowel superior to any germicidal action of chemical 
agents. The lesson we should endeavor to enforce by the presenta- 
tion of these facts, is the import of simplification in therapeutics, to 
which we have referred in previous issues. Since the prevalent falla- 
cious ideas on internal antisepsis may retard the progress of the sim- 
plified therapeusis, we direct the reader's careful attention to the 
study of this important question of the day, in the light of the facts 
here presented." 

As above observed, it is the ptomaines and toxines, rather than 
the bacilli, that we should aim to rid the intestines of. This we 
can do by irrigation, just as the vital forces aim to do by causing a 
diarrhoea to wash the intestines out. The greater the quantity of 
toxic ptomaines, the more profuse the diarrhoea. While I believe 
small doses of naptholine, salol, and benzo-napthol may aid in the 
disinfection of the intestines, boiled water, used freely, is perhaps all- 
sufficient. I have sometimes added peroxide of hydrogen to the 
water. It can do no harm, and may be beneficial. 

Diet. — The maintainance of intestinal antisepsis, with or with- 
out the use of antiseptic medicines, depends largely on the diet. 
This is really the most important part of the treatment. The food 



28 THE PRACTICE OF MEDICINE, 

should be of such a character as to be readily absorbed, and to con- 
tribute as little as possible to fermentation. The quality, also, is most 
important ; no more should be given than can be readily assimilated, 
for otherwise the food collects in the intestines, rapidly undergoes fer- 
mentation, noxious gases and solids are produced, and painful tympa- 
nites results. To prevent this, the most complete food is milk, diluted 
one-third or one-fourth with lime water, and shaken violently. The 
milk must be fresh, three or four hours at most from the cow, or 
thoroughly boiled if it is old. Malted milk is also an excellent food. 
Light watery soups made from Mosquera's beef-meal, or Libby's 
fluid beef are good. I do not advise any other of the proprietary 
beef preparations on the market. If the soup or beef tea is made 
at home, only the best lean beef or mutton should be used, and 
muriatic acid and pepsin should be added to it. Valentine's beef 
juice can be used if the stomach is very irritable, and in the stages 
of debility, as it can be given in cold water. Rice or barley should 
be boiled with the meat when the soup is made. The strong beef 
teas once in use I long ago discarded, as they keep up the tempera- 
ture and increase the delirium. Baked flour may be mixed with the 
milk when boiled ; such a milk gruel is often relished better than 
milk, and agrees better with the stomach. Copious drinking of pure 
water to the amount of two or three quarts a day, in addition to two 
quarts of milk, is now a very popular diet. Wine whey has long 
been popular, and I always prescribe it during the second week. 
Sherry is generally used, but I prefer Tokay if there is much weak- 
ness. In mild cases a pure white Rhine wine will do. In very 
severe cases brandy or whisky in milk will have to be used. I have 
seen benefit in cases of great exhaustion from the use of some of the 
wines of coca. No rule is so important, and more difficult to carry 
into effect, than a rigid adherence to a liquid diet for several weeks 
during convalescence. A little fish, a piece of bread, or a few mouth- 
f uls of fruit, have caused a serious or fatal relapse. A change of cli- 
mate and surroundings often hastens slow convalescence. 



SEWER-GAS FEVER. 

Definition, — This fever is caused by inhalation of noxious gases 
from defective sewerage, in cities, in buildings, and even from neglected 



FEVERS. 29 

privies in the country. Sewer-gas results from the fermentation of 
putrescent animal and vegetable matter, fcecal matter, and urine. 
In the process of fermentation marsh-gas, ammonia, hydrogen sul- 
phide, and other gases are freely given off. These gases may carry 
with them numerous pathogenenic microbes, especially those consti- 
tuting the contagion of cholera, typhoid fever, scarlatina, erysipelas, 
diphtheria, and other diseases. 

This fever may be caused by the toxic influences of others be- 
sides the typhoid germs, which have not been discovered, and which 
are capable of causing a fever as specific as typhoid. I am convinced 
from my observations that scarlet fever has been contracted by 
breathing the gases arising from defective sewers. I believe also 
that typhoid fever may be contracted in that way, and if other toxic 
germs are inhaled at the same time the results will be a continued 
fever of a very mixed character. 

Dr. Quain ("Diet, of Medicine"), writing of the causes of typhoid 
fever, says : " The occurrence of typhoid fever is traceable to the 
absence of proper sanitary arrangement in individual houses. Not 
to speak of the cess-pools and leaking drain-pipes allowing the base- 
ments to be sodden with sewerage sinks, or water-closets may be 
imperfectly trapped and sewer-gas diffuse itself through the apart- 
ments, or be drawn into the living-rooms by fires, or be forced into 
the house by pressure in the main drains, where the poison probably 
enters the system through the lungs." I italicize the above, because 
the writer overlooks the fact that the bacillus typhosis, or any other, 
need not necessarily enter the system through the lungs ; for when 
air (sewer-gas) impregnated with typhoid or other germs is breathed, 
many of these germs are arrested on their way by the surface of the 
pharynx, and especially is this so if the air be breathed through the 
mouth. Here they become entangled in the mucus, are swallowed 
in the saliva or with food, and may thus pass into the intestinal 
canal. It has been denied that this bacillus can be carried in the 
air ; but recently Dr. Bordas (" Therapeutic Gazette ") has under- 
taken a series of researches which appear to show that the bacillus 
of typhoid fever should be classed among the aerobic micro-organ- 
isms. It remains inactive in dry air, but lives and multiplies in 
air charged with vapor. Finally, he says there is nothing impossi- 
ble in the belief that the bacillus is capable of directly penetrating 



30 THE PRACTICE OF MEDICINE. 

the air-passages and thus starting the typhoid infection. But, as I 
have shown, this is not at all necessary. 

In my experience, sewer-gas fever is never typical typhoid fever. 
There is something in this deadly gas that more severely affects the 
nervous system and causes a virulent contamination of the blood, 
even when there is no fever. Witness the headaches, the insomnia, 
neuralgia, mental despondency, melancholia, and even insanity ; the 
eruptions on the skin, boils and carbuncles, the sore throat, ocular 
and aural symptoms. 

Dr. Kippax, in his excellent "Lectures on Fevers," says of 
typho-malarial fever : "It is a miasmatic disease due to the com- 
bined action of a malarial and septic poison." I cannot agree with 
him ; his " septic type " is the real sewer-gas fever. It is almost im- 
possible to imagine a typhoid, septic, and malarial complication, — 
i. e., all three poisons affecting the same persons at the same time. 
If he meant that the septic or sewer-gas poison alone was united 
with the malarial poisons, a better name would be septo-malarial 
fever. I believe a typical sewer-gas fever can exist without either 
typhoid or malarial addition. It assumes all degrees of severity, 
from a " walking " fever, where the temperature rarely goes above 
normal, to a high daily temperature of 103° F. or 105° F. In the 
epidemic of this fever which occurred about 1880 in the old Matte- 
son House in this city, and in several other dwellings in the same 
block, all grades of severity were observed. In many cases the tem- 
perature was sub-normal ; in the third and fourth week, paralysis, 
dementia, and other severe nervous sequelae, were common. The 
cause was found in a sub-basement flooded with sewerage, although 
the water supply had not been contaminated. The poisonous germs 
were in the atmosphere of the house. 

Treatment. — As soon as the physician is satisfied that the fever 
is caused by sewer-gas, the patient should be removed from the house, 
no matter how ill he may be. It is better to run any risk than to 
allow him to remain in the poisonous atmosphere. Kemoval into 
pure air may not arrest the disease, but it will greatly modify it, 
and allow our remedies better chance for favorable action. The body 
should be sponged several times a day with chlorine water, thymo- 
hydrastis diluted one to ten, eucalyptus water, or other disinfectant. 
The diet should be the same as directed under typhoid fever. 



FEVERS. 31 

The medicines which I have found most useful are, eucalyptus, 
baptisia, arseniate of strychnine, agaricus, iodide of arsenic ; and in 
addition I would strongly advise the use of hydrogen peroxyde, 
which bids fair to assume a very important role in the treatment of 
all infectious and contagious fevers, especially those which are caused 
by septic poisons in the system. It is better adapted to sewer- 
gas fever than to typhoid fever, although several physicians have 
reported excellent results from its use in the latter. Enough should 
be administered to saturate the contents of the intestinal canal. The 
efficient dose is from one teaspoonful of a fifteen-volume solution 
every hour, to one ounce every three hours. It should be largely 
diluted with water, one to ten. It is supposed to be perfectly innoc- 
uous ; it cannot antagonize any medicine above mentioned. 

If the fever is typho-septic, the medicines recommended for 
typhoid fever will be indicated. The same care should be taken in 
disposing of the excretions and the clothing of the patient. I am of 
the opinion that this kind of fever is not only infectious, but may 
be contagious. Medicines must be given in appreciable quantities 
in order to act in the presence of this pervading poison. I would 
advise the use of a decoction of eucalyptus leaves, one drachm to 
four ounces of water, a teaspoonful every two hours. The tincture 
of eucalyptus may be given in five-drop doses every two hours, alter- 
nated with arseniate of strychnia 2x or 3x, tablets (one-hundredth 
or one-thousandth grain), according to age, one every four hours all 
through the course of the fever. Iodide of arsenic is useful if the 
glandular system seems to be suffering particularly from the poison. 
Enemata of antiseptic agents, if thrown high enough to reach the 
lower portion of the small intestines, ought to be of great value, 
not only for their local but for their general constitutional action.* 

The preparations mentioned under typhoid fever would be appro- 

*A11 of the above intestinal antiseptics, from some cause, seem at times to 
disappoint us; and in this case we may try the bromide and lactate of strontium, 
lately introduced into therapeutics by Drs. Dujardin-Beaumetz and Germain See, 
who declare that the " toxic alkaloids, ptomaines, and leucomaines, in the human 
organism, do not form in the presence of the lactate." They assert that the bro- 
mide, when given in ten to thirty grain doses, causes a notable diminution of the 
gases of the intestines. It prevents the acetic and lactic acid fermentations, and 
destroys the gases of decomposition. It is safer than napthol, or the sulphite or 
salicylate of soda, and less irritating; besides, it exerts a calming influence in 
low fevers, and favors sleep. 



32 THE PRACTICE OF MEDICINE. 

priate ; also thymol, one to one thousand, using one or two quarts 
three times daily. Most of the medicines I recommended for typhoid 
are suitable in septic fever. 

One of the most distressing symptoms of this fever, as well as of 
typhoid, is the persistent dryness of the tongue, which often extends 
to the whole buccal cavity and pharynx, making deglutition and 
speech impossible. If neglected, the tongue cracks, bleeds, and 
ulcerates. A wash of glycerine and lemon juice is grateful, but 
needs to be constantly applied. In several distressing cases, I have 
prescribed pilocarpine muriate, one-twentieth of a grain (a hypo- 
dermatic tablet of that quantity, dissolved in a teaspoonful of water, 
or used hypodermatically) . The effect was excellent ; without caus- 
ing a copious flow of saliva, it kept the tongue and mouth moist. 
The relief was very grateful to the patient. 

ROCKY MOUNTAIN FEVER. 

Definition. — A continued fever occurring in the Rocky Moun- 
tain region at high altitudes, or in valleys and at the base of moun- 
tain ranges. By some this is considered a malarial fever, but it is 
doubtful if the bacilli malariae are found in the mountainous regions. 
Typho-malarial fever is equally a misnomer. The theory that it is 
purely a typhoid fever has not been proved by the discovery of the bac- 
illus typhosus. I have no doubt that at the present time the drinking- 
water of the mountain streams is sometimes contaminated with the 
typhoid poison, but it could not have been before that region was 
settled unless it was contracted from ice or snow water. It is now 
known that freezing does not kill all bacteria. Those who frequently 
examine ice, and have followed Tyndall, Cramer, Leone, Fraenkel, 
Engelmann, Prudden, and others in their investigations, know that 
water is only partially purified in freezing. The freezing process 
removed for Pengra only from twenty per cent to fifty per cent of 
the organic matter, forty per cent of the inorganic salts, and about 
ninety per cent of the micro-organisms. The diminution of bacteria 
in water in freezing is owing largely to their destruction, instead of 
expulsion. But some species of bacteria have great power of with- 
standing cold, and the bacillus of typhoid fever has been found in 
ice several months after its formation, and there are many other 



FEVERS. 33 

classes of germs that cannot be destroyed by freezing alone. When 
such impure ice is melted the living germs regain their activity, and, 
if pathogenic, are capable of producing disease. 

Impure snow-water is also sometimes detrimental to health. 
Some years ago Dr. Charles Smart, of the United States Army, 
traced the cause of the mountain fever to the melting snow of the 
Rocky Mountain streams, and inferred that the germs of this typho- 
malarial fever were brought down from the atmosphere by snow, 
remained frozen during winter, and then passed into the streams in 
an active condition when the snow melted in May, June, and July. 

Having seen but few cases myself, in persons who were attacked 
on the way from the mountains to Chicago, I do not feel competent to 
decide as to its nature. It seems to me a modified typhoid. For 
fuller information I wrote to Dr. L. D. Ordway of Denver, asking 
his opinion as to the nature of the fever and the most appropriate 
treatment, to which he replied as follows : 

" This so-called ' Mountain Fever ' in every respect so closely 
resembles typhoid that it might without much impropriety be termed 
false typhoid. Quite a number of cases of combined fever have 
come from other hands to my care (labeled typhoid fever) in which 
there has been no true iliac lesion or typhoid eruption. In fact, we 
have very little typhoid fever in the state of Colorado. I have seen 
and treated a few well-marked cases. Mountain fever may occur in 
isolated cases at any season, but the time when it is most prevalent 
is in August, September, and the first of October, this being the 
time of year when our mountain streams are the lowest, and thus 
the large quantity of mineral they carry in solution is the least 
diluted. This form of fever is not contagious, but prevails in these 
months, becoming thoroughly epidemic in our dry years. By dry 
years I do not especially refer to the amount of rainfall during the 
summer months, but to the small amount of snow that fell during 
the previous winter in the mountains, melting during the summer, 
and serving as a reservoir to keep up our streams. From these state- 
ments you will see that I attribute the cause to inorganic or mineral 
substances in solution in our drinking-water, instead of organic, as 
in true tpyhoid fever. 

"There is also some resemblance to the Pernicious Malarial 
Fever of the South, seen in the severe aching of back, limbs, and 



34 THE PRACTICE OF MEDICINE. 

head, character of tongue, especially at first, and the remission of 
the fever. The attack is not quite so insidious as in typhoid. The 
first symptoms usually noticed are lassitude of mind and body, soon 
followed by aching, in most cases of the whole body ; in all, some 
aching of the legs, back, and back of head. The fever usually 
is at first a little higher than in typhoid fever, but not running 
so high. 

" At the commencement the tongue is not so thickly coated as 
in typhoid ; it is yellowish, with red spots (pin-head), indicating 
congestion of liver and stomach ; it has more the general appear- 
ance of bilious remittent fever. The remissions of fever are quite 
marked, of course varying some, usually from 100° F. in the fore- 
noon to 104° to 105° F. in the afternoon in severe cases. Mornings 
you will often think from touch that there is no fever, but the ther- 
mometer soon dispels that idea. If remedies do not soon control 
the disease the tongue assumes a decided typhoid look ; in cases that 
get very low we have sudamina, but I have never seen the typhoid 
eruption on abdomen. At the first, along with the general aching, 
oftentimes the whole abdomen will become painful and sore to the 
touch, which never settles in the iliac region, and soon passes off the 
third day, sometimes sooner. About fifty per cent, during or at the 
close of this soreness of the abdomen, have several freely loose bil- 
ious stools, the others being constipated, with a history of having 
been so from two to ten days. In the cases treated homeopathically 
from the start, I have seen very little delirium. The kidneys, when 
not diseased before, are not more affected than in bilious fever, but 
when the kidneys are already weak or diseased they add serious 
complications. 

" Mountain Fever also differs from typhoid in this, that if taken 
early it may nearly always be aborted. As to its duration when 
not checked, it again resembles typhoid, passing through similar 
stages, and with about the same limitations and terminations. When 
it has been treated homeopathically from the first, results have been 
favorable. As with most other diseases, it differs considerably with 
different years. Three years since (a very dry season) it was much 
more severe, and with prolonged cases there was frequently hemor- 
rhage from the bowels ; but this hemorrhage seemed to me not to be 



FE VERS. 35 

from any particular spot of ulceration, but an outpouring from the 
capillaries, as in remittent fever of a low form. 

" In the first stage, when lassitude and aching are the leading 
symptoms, gelsemium and nux, both low, will abort many cases, — 
some will persist in aching until you will think of trying some other 
remedy ; but don't do so, except possibly in a few cases where the 
pain and soreness of the bowels predominates ; here bryonia and 
colocynth will control. Gelsemium continued throughout the case 
is the fever remedy par excellence; occasionally, and perhaps the 
only other fever remedy, veratrum viride. During the continu- 
ance of the disease the other remedies indicated are : iodide of 
arsenic, arsenic album, rhus tox.. baptisia. cinchona, and ipecac, — the 
last two controlling promptly the hemorrhage. There is a remedy 
indigenous to the Rocky Mountains : Sierra salvia, commonly known 
as mountain-sage. Among the Indians and old Spanish settlers this 
has a great reputation for curing mountain fever. Hearing so much 
of the mountain-sage. I obtained it, made a tincture, and tried it with 
some success ; but rinding the drug picture of gelsemium so con- 
stantly present, and getting such uniformly good results from it, I 
soon quit experimenting with the sage." 

YELLOW FEVER. 

Definition. — A continued fever produced oy the introduction 
into the human system of a specific poison. It consists of a single 
paroxysm of indefinite duration, but always tending to terminate 
in two or four days, or a multiple thereof. Its symptoms are : Epi- 
gastic tenderness : nausea ; projectile vomiting : redness of the eyes : 
violent frontal headache ; pains in the back and calves of the legs ; 
a slow, uncertain, easily compressed pulse ; a deep yellow or bronzed 
skin after the third day ; black vomit a few days previous to death : 
suppression of urine, and albuminuria. It has an average duration 
of six days. It is contagious. 

For a complete description of this fever, its etiology, diagnosis, 
and treatment, I refer the reader to Dr. Louis A. FaUigant's ex- 
haustive article in Arndt's " System of Practice." Dr. Falligant 
writes from personal experience, — and quotes such excellent author- 



36 THE PRACTICE OF MEDICINE. 

ities as Holcombe, Orme, Belden, Stout, and other physicians of our 
school in the Southern States. I never have treated a case, and 
therefore can add nothing to their successful method of treatment. 
Kippax gives the symptomatic indications for all the remedies likely 
to be useful. 



CHAPTER II. 
INFECTIOUS ERUPTIVE FEVEES. 



These fevers are all contagious. They are specially characterized 
by an eruption. They are all propagated by a distinct morbific 
agent, reproduced within the body, and are characterized by a defi- 
nite period of incubation. They run a clearly defined course, and 
are attended by an eruption which passes through a regular series of 
changes and then disappears. They rarely attack the same person 
twice. This description applies to their natural course. They are 
often quite erratic in their manifestations, and their variations ren- 
der them more dangerous. 

SMALL-POX— (Variola). 

Definition. — A highly contagious fever, lasting from two to four 
weeks. The eruption is pustular, and attacks both the skin and 
mucous surfaces. It has four distinct stages : (1) An initial stage, 
with chill, nausea, vomiting, headache, pain in the back, sore throat, 
active fever, rapid pulse, and sometimes an erythematous rash. (2) 
An eruptive stage, about the third day, when a reddish, millet-seed, 
or pin-head eruption appears, and a subsidence of the fever ; the 
eruption becomes dark-red and papular on the fourth day, slightly 
vesicular on the sixth day, pea-sized and umbilicated on the seventh 
day. (3) A stage of suppuration on the eighth or ninth day, when 
the pustules are fully formed ; then a secondary fever sets in, with 
very high temperature, the face swells, the itching is intense, and a 
loathsome smell emanates from the patient. (4) A stage of dessi- 
cation, on about the eleventh or twelfth day, when the pustules burst, 
crusts and scabs form, which on falling off leave pigmented cica- 
trices or pits. 

There are several varieties named : the distinct, confluent, and 
hemorrhagic. The stage of incubation varies from ten to thirteen 



38 THE PRACTICE OF MEDICINE. 

days. For a complete description see " Kippax on Fevers," or 
Arndt's " System of Practice." 

Small-pox patients are rarely treated in private practice. In 
city and country they are relegated to the pest-house. If vaccina- 
tion were universal, made with pure vaccine matter, and repeated as 
often as every five or seven years, it would disappear forever. Yet 
there are presumably conscientious physicians, particularly in 
England, who denounce vaccination, and assert that its effects are 
worse than the small-pox. Admitting that occasionally blood-pois- 
oning does result when the operation is performed with impure imple- 
ments, and with impure matter, it is inconceivable how sane men can 
make such a statement, and believe it. 

Treatment. — My experience has been limited to a few cases. In 
the early part of my practice, a gentleman went from the town where 
I practiced to New Orleans. A few days after he returned he was 
taken ill with what appeared to be the first stages of malarial fever. 
On the fourth day the eruption appeared, and on the fifth day I 
diagnosed small-pox. The town authorities, at my suggestion, built 
a high fence all around the house, and diverted the road that ran by 
it to a distance of one-eighth of a mile. It was a week or more 
before I could procure any vaccine virus that was humanized ; bovine 
virus was not then being used. All the six inmates of the house 
were vaccinated. On the twelfth day from the exposure to the fever 
all came down with the incipient symptoms except an old gentleman 
who had been vaccinated twenty years before. The others had never 
been vaccinated. They had the fever, and a scanty eruption appeared, 
which dried up about the time the vaccine pustule was ripe. They 
were not very sick, and recovered in a few days. This taught 
me the wonderful efficacy of vaccination. The first patient was very 
ill, and passed through all the loathsome stages of the disease, leav- 
ing him badly scarred, but otherwise in good health. Since that 
experience I have treated perhaps a dozen cases. This, and the tes- 
timony of our school, leads me to believe that the chief remedy in 
all stages of the disease is tartar emetic. It should be prescribed 
in doses of one-one-hundredth (2x) of a grain, or its equivalent, in 
aqueous solution, and administered every two hours. It is the true 
similimum of the whole disease. Only when the primary, and espe- 
cially the secondary high temperature is excessive, may gelsemium or 



INFECTIOUS ERUPTIVE FEVERS. 39 

veratrum viride be more useful. If the pain is very intense, cimicif uga 
or phenacetin may relieve. I never could understand or verify the 
recommendation for thuya in this disease. Sarracenia was at one 
time recommended, but experience has not confirmed its value. 
The complications must be treated according to their pathology and 
symptoms, if they become severe enough to call for interference. I 
have found turpentine useful in the hemorrhagic variety. 

The sick-room should be large, well ventilated, and darkened 
moderately, with equal temperature of 65° to 70° F.; it should be 
heated by a fireplace or grate, and no carpet or upholstered furni- 
ture should be in the room. The skin should be bathed with diluted 
thymo-hydrastis fluid. During the suppurative stage, a one-tenth 
solution of peroxide of hydrogen should be applied to the skin by 
means of compresses of cotton or lint ; this destroys the malignity 
of the piis, and prevents pitting, if the pustules are not rubbed or 
scratched. A powder called " calendula-borine " may be used by 
dusting the surface thoroughly with it. If the mucous surfaces are 
much pustulated, administer the peroxide of hydrogen, a teaspoonful 
in an ounce of water every two hours. The diet should vary with 
the stages of the fever ; cold water and buttermilk may be allowed ; 
ice-cream is very grateful, eaten slowly, and is safe. If stimulants 
are used, the red wines are to be preferred. 

VARIOLOID. 

An acute contagious disease, due to the small-pox contagion, 
occurring only in individuals that have been successfully vaccinated, 
or who have had variola. It runs through the same stages as small- 
pox, but is of shorter duration, and may abort at any period. The 
treatment is the same as for variola. 

VAEICELLA — (Chicken-Pox). 

This is an acute epidemic contagious disease, occurring generally 
in children. The eruption consists of oval, isolated, hempseed- 
sized vesicles, appearing in successive crops. It occurs only once 
in the same individual. The period of incubation is eight days ; it 
lasts from four to seven days. It is likely to be mistaken for vario- 
loid. I have seen cases that were almost as severe, but the period 
of invasion of varicella is longer, the fever more intense, the erup- 



40 THE PRACTICE OF MEDICINE. 

tion appears later, and shows on the face first, while varioloid shows 
on the body first. Kippax says that the eruption of chicken-pox is 
not umbilicated, but my observation is different. Usually a few 
pustules on the face are umbilicated, and leave pits ; very few chil- 
dren escape without some pits on the forehead or cheeks. The 
treatment, when any is necessary, is the same as for varioloid. 
There is no need for isolation ; it is such a trivial disease that no 
one should dread it. 



SCARLET FEVER. 

Definition. — An acute epidemic infectious fever, characterized 
by a scarlet-red rash on the body and extremities, accompanied by 
sore throat. It runs its course in seven or ten days, and ends by 
desquamation, which usually lasts two weeks. The period of incu- 
bation varies from two to eight days. Eustace Smith says twenty- 
four hours in some cases, and that six days is the average. The 
patient may give the infection during the first days, but the most 
infectious period is during the time of desquamation, and does not 
cease until the skin has entirely peeled. Sporadic cases are met 
with, and there are cases which doubtless arise from filthy surround- 
ings alone. The epidemics vary greatly in severity. Some are so 
mild as to be called scarletina or scarlet rash, being very mild and 
transient. Epidemics of scarlet fever are made worse by filthy sew- 
erage. Open cess-pools and sewer-gas in residences aggravate the dis- 
ease terribly. Scrofulous and ill-cared-f or children suffer badly from 
it. The rash appears as scarlet points not elevated above the sur- 
face ; these are closely set, and their borders, which are paler than 
the centre, unite so as to produce a uniform pink ground, dotted 
over with scarlet points. The color of the rash disappears on pres- 
sure with the finger. The eruption may be confluent or not ; when 
not confluent it may be mistaken for measles. In bad cases it may 
be dusky or purple. There is often a good deal of irritation and 
some oedema, making the fingers look stiff and clumsy. During the 
eruptive stage, which lasts about six days, the temperature runs as 
high as 105° or higher, the pulse being from 120 to 160, hard and 
vibrating. Vomiting is severe, the thirst intense, the skin hot and 
dry. When the rash fades, the fever usually declines. During the 



INFECTIOUS ERUPTIVE FEVERS. 41 

eruptive stage, the tongue, which at first is dry and coated, becomes 
red, and presents the " strawberry " or " cat's tongue," so charac- 
teristic of the disease. The throat is red, tumefied, and often ulcer- 
ated. In malignant cases all these symptoms are exaggerated. The 
eruption may not appear at all, but, instead, convulsions ; or the rash 
may appear on one part of the body, or on one extremity, or hav- 
ing appeared for a short time, suddenly disappears, and coma or 
convulsion sets in. The complications are : (1) oedema of the glot- 
tis ; (2) abscesses about the throat ; (3) diphtheria ; (4) endocar- 
ditis, which is the most common complication, and is generally 
ulcerative ; (5) pericarditis, not so common, but I have frequently 
met with it ; (6) rheumatism often occurs during the desquamative 
period, and is sometimes associated with suppurative synovitis (so- 
dium salicylate is regarded as specific for this rheumatism, in small 
doses, 1 to 2 grains every hour, until improvement sets in); (7) 
otitis, when it occurs, is more destructive than after measles, and often 
ends in mastoid abscess ; (8) ozena, from caries of the nasal bones ; 

(9) chorea, complicating, or a part of, the rheumatic endocarditis ; 

(10) catarrhal and parenchymatous nephritis, presenting all the 
characteristics of acute Bright's disease, leading to dropsy ; and 
finally, (11) inflammation of Peyer's patches, as in typhoid. 

Treatment. — If there were really a prophylactic treatment that 
would absolutely prevent the disease, or arrest it in the stage of incu- 
bation, it would be a great boon to humanity. Hahnemann's recom- 
mendation of belladonna has been partially verified by physicians of 
both schools. Eustace Smith says : " It has now been proved to be 
useless "; while Dudgeon and Bayes, of our school, declare that it 
has protective virtues. But the truth is probably as Hughes states 
it, namely, that Hahnemann had reference to the scarlet fever of 
Sydenham, with bright red smooth skin, not the discreet, nor the 
confluent, nor the dusky and mottled eruption. The old school exper- 
imenters who gave belladonna did not follow Hahnemann's directions 
—to give a drop of the third dilution every three days ; instead, they 
gave the mother tincture in quantities enough to cause its physiological 
effects. My conviction is, that when given in an epidemic of the smooth 
red scarlatina, even in doses of the lx dilution, it may act as a 
prophylactic. I know to a certainty that it will modify all cases of 
non-malignant scarlet fever if given during the prodromic, or inva- 



42 THE PRACTICE OF MEDICINE. 

sion, stage. Eustace Smith (" Diseases of Children ") recommends 
arsenic as a remedy of great value; but with singular inconsistency 
he combines it with sulphurous acid, and then gives all the credit 
to the arsenic. His formula for a child is : 

3^ Fowler's Solution q. s., as much as the 

child will bear, probably 1 to 3 drops. 

Sulphurous acid gtt. xv. to xxx. 

In a little syrup of poppy, three times a day. 

He quotes an authority who gave it to one hundred children that 
had been exposed to the infection of scarlatina, and in only two did 
the fever occur, and both cases were very mild. Now, if the arsenic 
or sulphurous acid had been used alone the testimony would be 
worth something. I think the arsenic is worth a trial when the pre- 
vailing type of the epidemic is malignant. Sulphurous acid is also 
worth a trial. The sulpho-carbolate of soda, so highly lauded by 
one of our school several years ago, proved utterly worthless. Sal- 
icylic acid, in one-fifth grain doses, is said to be an efficient prophy- 
lactic. If we could find some microbic poison which bears the same 
relation to scarlet fever that vaccine does to small-pox, its introduc- 
tion into the system by inoculation might prevent or modify the 
intensity of the former. It has been suggested that in the " foot- 
and-mouth disease " of cattle such a preventive poison has been 
found. Milk from such diseased cattle, when drunk, causes symp- 
toms very similar to scarlatina ; it has therefore been suggested that 
the lymph of the peculiar vesicles that appear on the feet of cattle 
could be so modified as to be fit for inoculation, but I am not aware 
that any conclusive experiments have been made. 

Isolation must be carried out in every case. The patient is to 
be put into an upper room, or one separate from the living-rooms ; 
this room must be large and well ventilated, and kept at a tempera- 
ture of 65° to 70° F.; all woolen fabrics on the bed, and all furni- 
ture, should be removed from the room and the carpets taken up ; 
sheets should be hung up in the doors and windows, and kept wet 
with some disinfectant, as the eucalyptus water, made from Sanders 
eucalyptol. The skin should be rubbed thoroughly every day with 
mild carbolized vaseline, or eucalyptol vaseline, (one drachm to two 
ounces) ; inunctions with benzoated lard is very popular with some 
physicians. The discharges of urine aud foeces must be destroyed. 



INFECTIOUS ERUPTIVE FEVERS. 43 

and all discarded clothing thoroughly disinfected ; nurses must not 
mingle with the family until the desquamative stage has passed. If 
the physician handles the patient, he must disinfect his hands and 
his thermometer. I would recommend that a steam atomizer be 
kept going in the room day and night charged with eucalyptol water. 
Some very favorable results have followed this plan. This prepara- 
tion can be prepared by any one, as follows: One drachm of 
eucalyptol is triturated with two drachms of carbonate of magnesia 
and one drachm of alcohol ; then add one quart of water and filter. 

After recovery, or death, the room should be thoroughly disin- 
fected with the fumes of sulphur or chloride of zinc, or sanitas ; and 
all the clothing and bedding subjected to boiling in one of the above 
liquid disinfectants. Even with all these precautions, a child sleep- 
ing in the room may contract the disease years after. Another 
method mentioned in " Science " should be adopted : " Infective 
germs or spores float as impalpable dust in the air. Wet gauze, by 
evaporation, becomes colder than the surrounding air. Dust is 
attracted from a warm air to a cold body. If the substance is wet, it 
adheres. By canopies of mosquito netting over the sick-bed, kept 
wet with bichloride of mercury solution (one to five thousand) con- 
taining glycerine, no dust can pass through the meshes in either 
direction. The cooled threads attract across the narrow space of 
mesh all dust that reaches there. The glycerine and water fix it ; 
and the corrosive sublimate sterilizes it. Two layers of netting are 
required, so that the outer one can be removed every day and wrung 
out in a fresh solution. This isolates the patient perfectly, even 
from persons occupying the same room." 

Mild cases in an ordinary epidemic do not need all these disin- 
fectant measures, and but little medicine. Aconite and belladonna 
will conduct the malady to a favorable ending. But severe cases 
tax the skill of the physician to the utmost. The similimum should 
be carefully selected, and continued as long as it is indicated. Great 
harm is done by frequently changing the medicine, because it does 
not seem to remove the symptoms. We should remember that all 
we can do is to modify the aspects of the case, not arrest it. If the 
high temperature and external heat call for aconite, gelsemium, or 
veratrum viride, use them boldly, until an impression is made on 
the fever. Each one can be alternated with belladonna, hyoscyamus, 



44 THE PRACTICE OF MEDICINE. 

stramonium, or ailantus. Chloral hydrate, when taken to excess, 
causes an eruption on the skin exactly simulating that in scarlet 
fever. I have had several cases of chloral poisoning in which -the 
stupor, bright red eruption, and general appearance, bore a close 
resemblance. The high temperature only was wanting to complete 
the picture. 

Singularly, Professor Wilson, of the old school, has written sev- 
eral articles recommending chloral. He says : " The treatment of 
scarlet fever by the use of chloral has given me better results than 
any other ; it seems to be almost a specific for the disease. From 
the beginning give chloral in doses of two to five grains, according 
to the age of the child, and at intervals sufficient to keep the patient 
constantly in a slightly somnolent condition. Give the chloral in 
syrup of lactucarium, and it will be taken very readily by the child." 
If this experience should be verified, it will be a strong proof of the 
principle of similia. In some cases, when the oedema of the cellular 
tissue, face, hands, and feet were prominent, I have used apium- 
virus with the happiest results. It not only modifies the eruption, 
but acts favorably on the kidneys, so as to prevent nephrites. I pre- 
fer the lx or 2x trituration in water, repeated every few hours. 
Next in importance I have found arsenicum and rhus tox.; the for- 
mer when the eruption was dusky, purpuric, or mottled, and a malig- 
nant type threatened. Rhus tox., like quinine, may be useful in 
certain cases if the idiosyncrasy is favorable, as I mentioned under 
measles. 

In the hemorrhagic variety, turpentine is invaluable. The red 
glazed tongue, the dark eruption, and the passive hemorrhages, espe- 
cially from the kidneys, fully indicate this potent remedy. When 
there is foetor, and acridity of all the secretions, phytolacca, eucalyp- 
tus, and iodide of arsenic, will modify the condition. When the 
throat ulcerates, and the glands swell and threaten to suppurate, use 
mercurius iodide, or cyanuret, alone or alternated with phytolacca. 
These are also good remedies for a diphtheritic complication. There 
is a phase of scarlatina] malignancy, when the blood loses its plas- 
ticity and becomes disorganized, in which the ophidian poisons are 
valuable. Some of the worst cases in my practice were cured with 
lachesis ; and I have seen crotalus and naja remove very threaten- 
ing symptoms. In cases of non-appearance, or retrocession of the 



INFECTIOUS ERUPTIVE FEVERS. 45 

eruption, if the patient's vitality was not too depressed, I have had 
good results from pilocarpine. Under its use the eruption will some- 
times appear. The treatment of cardiac complications requires close 
attention and high diagnostic skill. They require the careful use of 
bryonia, cactus, strophanthus and digitalis. This rheumatism does 
not require the remedies for ordinary rheumatism, because it depends 
on a different morbific cause. I have had the best results from 
eucalyptus, iodide of arsenic, and iodide of lithia. Post scarlatinal 
dropsy can be treated only through an action of the kidneys by well 
chosen renal remedies, such as are indicated in Bright's disease. 
Apis is a splendid remedy when there is parenchymatous nephritis, 
when only albumen is found in the urine, and there is general 
anasarca, benzoate of ammonia, when the urine is a dark, mahogany 
red, has an offensive ammoniacal smell, a smoky appearance, and is 
very scanty. Benzoate of lithia and benzoic acid are useful in the 
same condition, but are not so active. Arsenic has never appeared 
to be of benefit in my experience, in the anasarca following scar- 
latina or any other dropsy. I have long ceased to use it for that 
purpose. I think it has been greatly overrated, probably because 
the oedematous condition caused by arsenic is due to a faulty condi- 
tion of the blood rather than to a nephritic origin. Cantharis is in- 
dicated for a stage of renal disease in advance of that caused by apis, 
namely, when with the albumen there is found blood and fibrinous 
casts, and an almost complete suppression of urine. Turpentine is 
useful in a condition still further advanced, when there is a passive 
hemorrhage from the kidneys, showing as a black, " sooty " sedi- 
ment ; the urine is very scanty, loaded with albumen and casts, and 
the heart becomes poisoned by retained toxic material. The oil of 
hedeoma is a close analogue of turpentine, with very similar symp- 
toms. Apocynum, when it can be borne by the stomach, will rap- 
idly relieve anasarca when the kidneys are not seriously affected. It 
is better for cardiac than for renal dropsy, and ranks with digitalis 
and adonis. I have found that the bitartrate of potassa (cream of 
tartar), if pure, dispels scarlatinal dropsy when other medicines fail. 
I cured my own son with it, when the dropsy seemed to assume a 
dangerous character, no urine having been passed for several days. 
The dose found effective was ten grains every three hours, in sweet- 
ened water. After six or eight hours, evacuations occurred from 



46 THE PRACTICE OF MEDICINE. 

the kidneys and bowels, which continued until the anasarca disap- 
peared. In many other instances I have used it with as good re- 
sults. 

RUBEOLA — (Measles). 

Definition. — Measles is an acute epidemic contagious disease, 
lasting about seven days. It occurs mostly in early life ; is gener- 
ally unattended with danger, but is especially liable to complications 
and sequelce. The eruption first resembles red spots like flea-bites, 
that coalesce into crescents. Measles rarely recurs in the same indi- 
vidual, but Eustace Smith (" Diseases of Children ") asserts that 
" of all the eruptive fevers, measles is, next to typhoid, the one 
most liable to return." The period of incubation lasts from nine 
to twelve days. 

Symptoms. — The complaint begins with signs of a severe cold ; 
the patient sneezes, coughs, his eyes look watery and red, there is 
fever, headache, the nose may bleed, there is soreness in the chest, 
and hoarseness. If the fever is high, there may be delirium and 
convulsions. The skin is generally moist, even when the tempera- 
ture is 103° F. or higher ; the eruption usually appears on the fourth 
day, when the fever and catarrhal symptoms are aggravated ; it is 
first seen about the chin, temples, and forehead, and spreads down- 
wards on the trunk to the feet. The rash begins to fade in twenty- 
four to forty-eight hours, leaving the face quite free while it is still 
visible on the feet. The rash varies in appearance from the simple 
crescentic form, to nodules of a dark purple hue, hard and scattered, 
almost resembling variola. The catarrhal inflammation often extends 
to all the mucous surfaces, the throat, eustachian tube, middle ear, 
bronchia, stomach, and bowels. At the last, a fine desquamation of 
the skin occurs, often unnoticed — unlike the shedding of the skin 
in scarlatina. 

There is occasionally an epidemic of so-called " black measles," 
or ordinary measles may assume that character in delicate children 
during a mild epidemic. The fever in such cases assumes a typhoid 
character. The eruption comes out in irregular patches, and is of a 
dark-red or violet hue, and the skin is thickly spotted with pete- 
chia. The pulse is small, feeble, and quick ; respiration rapid ; 
tongue dry, brown, and quickly furred ; temperature high, with 



INFECTIOUS ERUPTIVE FEVERS. 47 

muttering delirium, coma, and convulsions. Such cases generally 
prove fatal. The complications of measles are convulsions, which 
sometimes usher in the attack, and may appear several times during 
the first day, but are seldom dangerous. If they occur during the 
eruptive stage, they should cause some anxiety. Hemorrhages from 
the nose, kidneys, and bowels occur in bad cases. Diarrhoea and 
dysentery often render the disorder dangerous. Laryngitis is fre- 
quent, and leads to croupous cough which alarms the parents, or 
leads to a hoarseness which becomes lasting. Ophthalmia and otitis 
are very common, and leave permanent irritation of the lids, and 
deafness. Pneumonia and capillary bronchitis often lead to a fatal 
issue. Eustace Smith says : " Tuberculosis is an undoubted and 
fatal consequence of measles." 

Treatment. — In all the self -limited eruptive fevers we should not 
try to interfere with their normal progress. To do so would be to 
create unnatural conditions. The fever, the catarrhal discharge, and 
the eruption, the three characteristic processes of measles, are efforts 
of the vital principle or force to eliminate the poison of the malady. 
Our aim, then, should be exerted to aid the vital force in its work, 
and make the patient as comfortable as possible under the circum- 
stances. The room in which the patient lies should have a good 
ventilation, without draughts, with a uniform temperature of 70° F. 
The patient must not be kept dirty ; the skin should be frequently 
sponged off with warm water, rendered alkaline by means of borax 
or soda. There is no danger from bathing if only a portion of the 
body is exposed at a time. Neither should the patient be made to 
swelter under thick clothing. It only increases the liability to 
catch cold. Use woolen covering altogether ; cotton quilts, which 
do not allow bed-ventilation, should be banished from every sick- 
room. There is a traditional fear of cold drinks in measles ; this is 
unfounded so long as the patient is feverish. Ice-water or very cold 
water should be withheld, but the water may be cool enough to be 
agreeable. If the patient be chilly, and the eruption does not appear, 
or if the surface of the body is cool, then hot beverages should be 
given. Hot weak tea and hot lemonade are very agreeable and 
beneficial. In such cases the appearance of the eruption is favored 
by increasing the temperature of the room to 80°, and in some cases 
packing the whole body in sheets wrung out of hot mustard -water. 



48 THE PRACTICE OF MEDICINE. 

In mild, normal cases no medicine is really needed, but it is diffi- 
cult to educate the laity to the safety of a purely expectant treat- 
ment. Those medicines should be selected whose effects on the 
human body approach most nearly to the manifestation of the poison 
of measles, namely, those which cause catarrhal symptoms and an 
irritation of the skin. In no other way can medicine aid the efforts 
of the vis medicatris naturce. 

The medicines that most closely imitate the action of the micro- 
coccus of measles are, for mild cases, pulsatilla, euphrasia, kali hyd, 
and gelsemium ; for severe cases, arsenic, iodine, belladonna, phos- 
phorus, and bromine. There are some drugs that would be useful 
in measles were their action on the human system always the same. 
I refer to quinine, antipyrin, copaiva, cubebs, and rhus. These 
drugs all cause catarrhal symptoms, fever, and eruptions on the skin 
similar to measles, but only in a few persons. Those affected by 
them in that way are so because they have an idosyncrasy for those 
drugs. To give these drugs to all persons when indicated is illogi- 
cal, because probably not ten in every one hundred patients will be 
affected by them. It is well known that rhus tox., so often given 
in various cutaneous and rheumatic diseases, is often very disap- 
pointing in its action. For many years I have found that it acts 
most favorably on those who know they are susceptible to its poison- 
ous effects. Many persons know that they are not susceptible to 
it, because they can handle and even chew the leaves with impunity. 
To such it is useless to give rhus tox. It simply has no influence 
whatever. The same may be said of the other medicines. We can- 
not prescribe them with a certainty of getting curative results unless 
the patient is susceptible to those peculiar effects that resemble the 
poison of measles. My plan of treatment has been to prescribe 
aconite, gelsemium, or veratrum viride, in alternation with pulsatilla, 
euphrasia, or iodide of arsenic, according to their specific indications 
in the beginning of the attack, and make no change unless they fail 
to ameliorate, or some complication occurs. Aconite is only useful 
when its peculiar anxiety, restlessness, and wiry pulse is present ; 
gelsemium, when the patient is indifferent, drowsy, with scarlet red 
face, puffy and hot, with a soft, large pulse, and a tendency to con- 
vulsions ; veratrum viride when, with large, hard, bounding pulse, 
convulsions are imminent. Pulsatilla has a large sway over the 



INFECTIOUS ERUPTIVE FEVERS. 49 

catarrhal and aural pains and conjunctival affections, and presents a 
good picture of measles. The catarrh is bland, and the discharge 
soon changes from watery to thick yellow mucus. 

Euphrasia has eye and nasal symptoms, more decided than Pulsa- 
tilla. The eyes are redder, the tears scalding ; there is an eruption 
on the skin like the first stages of measles, but the ears are rarely 
affected. It should be used oftener than it is, for it is superior to 
Pulsatilla in many cases. Our indigenous pulsatilla Qp. nutalliana) 
acts better in many cases than the foreign plant. 

Iodide of potash, or, better still, the double iodide of mercury 
and potash, presents a graphic picture of the most aggravated man- 
ifestation of the catarrh of measles. Both have violent sneezing, 
acrid profuse discharges, excoriating the skin when it comes in con- 
tact with it. The catarrh extends to the bronchiae, larynx, and tra- 
chea ; there is aching, burning, and throbbing in the frontal sinuses, 
and in the antrum of the malar bone. Iodide of arsenic causes a 
catarrh that is more irritating and malignant, and one only equalled 
by that of kali bichromicum. In some cases phosphorus, hepar 
sulphur, sanguinaria nitrate, spongia, and arum triphyllum will be 
indicated. 

If the ophthalmic and aural complications threaten disorganiza- 
tion, send your patient to a specialist, when convenient. Otherwise, 
consult Winslow, Norton, and other authorities. For the treatment 
of other complications and sequelae, I refer to the special mention 
of those affections. Patients should be watched carefully for sev- 
eral weeks, in order to ward off sequels, especially the tendency to 
tuberculosis. In the so-called " black measles," the purpuric and 
hemorrhagic forms, prompt and heroic treatment is required. The 
patient will need stimulants, of which an egg-nog, or brandy beaten 
up with egg, or a good dry champagne, are the best. The chief 
medicines are arsenic, ailantus, turpentine, eucalyptus, and quinine. 
The indications for arsenic are well known. It is especially called 
for when there is dirty, offensive diarrhoea. Ailantus has been of 
value in some cases. The eruption is livid, petechial, with low de- 
lirium, great prostration, small weak rapid pulse, foetid discharge 
from the nostrils, cracking of the corner of the mouth, a watery, 
offensive, excoriating diarrhoea. 

Terebinth is often indispensable. It has a petechial and pur- 



50 THE PRACTICE OF MEDICINE. 

puric eruption, hemorrhages from the kidneys and bowels, dry red 
glazed tongue, retention of urine, rattling cough with mucus in the 
bronchi which the patient cannot expectorate. The general state 
imitates a certain stage in typhoid for which terebinth is almost 
specific (dose, one to three drops of the lx every two hours). 
Phosphorus has many symptoms in common with turpentine, but it 
has not the peculiar appearance of the tongue. Quinine in large 
doses has caused petechial eruptions, with hemorrhages, deafness, 
prostration almost to collapse, in some persons. In some cases I 
found it of great value. The arsenic of quinine is probably the best 
preparation in such cases (dose, one grain of the 3x). 

Bronchorrhoea is one of the most obstinate of the sequels of 
measles. It may last for years, and lead to humid asthma, and pre- 
pare a good soil for the tubercle bacilli. I had indifferent success 
until I adopted the following treatment : If the cough was " rat- 
tling " and coarse mucous rales could be heard all over the chest, if 
the quantity of mucus caused an asthmatic or " wheezy " breathing, 
and if the expectoration was yellow or greenish, I gave copaiva 
balsam, and a marked improvement soon set in. The dose varies 
with the age. For adults, one or two drops of the pure balsam, every 
three hours ; for children, the lx to 3x dilution. Porous discs will 
absorb one drop of the balsam, or dilutions. When the bronchial 
cartarrh was attended with some hectic fever, eryodiction (yerba 
santa) is equal to copaiva for the same symptoms. I found five 
drops (lx) to be the curative dose for children, and ten to twenty 
drops for adults. When the asthmatic respiration was quite marked, 
but the expectoration was glairy transparent or white, grindelia 
robusta was the remedy. Dose same as yerba santa. Sometimes the 
expectoration becomes purulent. Then if the tubercle bacilli is 
found in the sputum, kreosote or myrtol are the specific remedies. 
I find they act best when given in syrup of balsam Peru ; to each 
ounce of which add 8 drops of the lx dilution, and order a teaspoon- 
ful every three hours. In cases of sudden retrocession, or non-ap- 
pearance of the eruption, prompt measures are required. Besides the 
hot packs I have found jaborandi, or one-twentieth grain of its alko- 
loid, pilocarpin, will cause the skin to flush, become hot, and covered 
with sweat. That is just what we desire in such instances. Under its 
influence the eruption will soon reappear. When the patient is 



INFECTIOUS ERUPTIVE FEVERS. 51 

influence the eruption will soon reappear. When the patient is 
verging on collapse, with coldness and feeble pulse, I have brought 
about reaction with glonoine aided by phosphide of zinc. We should 
not fear to use palliatives in order to conduce to the comfort of our 
little patients. The cough, particularly, is so persistent and irrita- 
ting that it prevents sleep, and excoriates the mucous surfaces of the 
air-passages, that are already in a high state of irritation. When 
drosera, rumex, and hyoscyamus do not alleviate, use one tablet of 
Dovers powder lx every hour ; or a teaspoonful of syrup lactucarium 
every half -hour ; or one grain of codiene 2x, until the cough ceases 
to annoy. I never saw the slightest injury from these palliatives, 
and I believe it is our humane duty to use them. 



EPIDEMIC ROSEOLA. 

Definition. — A mild infectious complaint, called sometimes ro- 
theln, or German measles, having a close resemblance to measles, 
and is probably frequently confounded with it. The two diseases are, 
however, not the same, for rotheln does not protect against measles, 
and often occurs soon after a person has had measles. It has been 
mistaken for scarlatina, and has been called a " hybrid scarlatina." 
The stage of incubation is said to last a week. A violent back-ache 
often attends the first day of the disease. There are very few ca- 
tarrhal symptoms, but the eyes are often red. At first the tonsils 
may be swollen, and this sore throat may return on the fifth day. 
This secondary sore throat is characteristic of rotheln. The erup- 
tion is composed of dusky-red slightly elevated papules, first appear- 
ing on the cheeks and sides of the nose. The wrists and ankles are 
attacked almost as soon as the face. It then spreads all over the 
body. The eruption differs from measles in that the spots do not 
group themselves in crescentic patches ; but large patches of confluent 
redness may appear on the cheeks, wrists, and fore-arms. There is 
some itching and a fine desquamation. The temperature on the 
fourth and fifth days may reach 104°, and the voice may be thick, 
owing to a sticky mucus in the throat. Sometimes the glands of 
the neck are enlarged and tender, as are the post-cervical, inguinal, 



52 THE PRACTICE OF MEDICINE. 

and axillary. Some epidemics are much milder than this descrip- 
tion and some much more severe. 

Treatment. — The same hygienic measures as for measles. Some- 
times belladonna and gelsemium may be required ; also mercurius, 
iodine, ammonium muriaticum, and phytolaccan. Often no medicine 
is needed. 



CHAPTER III. 
SPECIFIC INFECTIOUS DISEASES. 



DIPHTHERIA. 

An acute specific infectious disease, highly contagious, of a low 
type, of which the chief local manifestation is a deposit of fibrin on 
the pharyngeal and naso-pharyngeal mucous surfaces, and on those 
of the upper air-passages. Exceptionally the exudate appears upon 
the mucous membrane of other regions and upon the skin. With- 
out giving the history and etiology of this disease, which has been 
so exhaustively treated by Dr. Jacobi, Dr. J. S. Mitchell, and many 
other authorities, in the libraries of all physicians, I will make a few 
observations, the result of my own experience. (1) I believe that 
pseudo-membraneous croup and diphtheria are two essentially differ- 
ent diseases. There is certainly a diphtheritic croup caused by an 
extension of the membrane downward into the larynx, if it has not 
attacked the larynx first. It is just as certain that there is a 
croupous laryngitis, which does not arise from any specific poison, 
but is an aggravated catarrhal process. I have treated many such 
cases when there was no diphtheria in the same village or township, 
and when neither the child nor any person in the house had been 
exposed. These cases supervened on a common cold that affected 
all the members of the household, only one of whom had mem- 
braneous croup. (2) I do not believe that diphtheria can arise from 
filth alone, but the presence of filth, especially the gaseous form (as 
sewer-gas), greatly aggravates all cases subjected to its influence. 
I am sure, however, that cases of diphtheria do arise from sewer-gas 
containing the microbes of that disease. In a discussion on diph- 
theria, published in the "British Medical Journal," Dr. Russell 
cited several instances in which steam had seemed to be an active 
factor in the propagation of the disease. Hot water and steam from 
a brewery were introduced into some old cesspools, and evidently 



54 THE PRACTICE OF MEDICINE. 

wakened into activity germs which, if undisturbed, would have re- 
mained dormant. An epidemic of diphtheria soon developed in the 
vicinity, and was not checked until the steam was turned into other 
channels, when it quickly ceased. If, as we now believe, the bacil- 
lus of diphtheria develops with special rapidity in the presence of 
warmth and moisture and absence of light, it is not unreason- 
able to suppose that the introduction of hot water or steam into 
cesspools or sewers may be a most dangerous procedure. (3) That 
it is contagious as well as infectious, the case cited by Mitchell 
("Arndt's Practice ") seems ample proof, as I can substantiate from 
personal observation. (4) My observations convince me that the 
disease may occur twice or more in the same individual. One of 
my patients had genuine diphtheria several winters, and finally died 
of it. (5) As to the nature of the contagion, the conclusions of 
Wood and Formad appear most reasonable : " The contagious ma- 
terial of diphtheria is really of the nature of septic poison, which is 
locally very irritating to the mucous membrane, so that when brought 
in contact with that of the nose and mouth it produces an intense 
inflammation without absorption by a local process. Whilst absorp- 
tion is not necessary for the production of the angina, it is very 
probable that the poison may act locally after absorption, by being 
carried in the blood to the mucous membrane." The claim made 
by some pathologists that diphtheria is always a purely local disease, 
before auto-infection from the locality affected, seems to me impos- 
sible. What physician in large practice has not seen violent consti- 
tutional symptoms and death occur without a local lesion anywhere 
discoverable? In such cases the septic material absorbed from 
without poisons the whole system, especially the nerve-centres. The 
strange unsusceptibility of physicians, and of some children, to the 
infection of diphtheria under the worst circumstances is yet an un- 
solved problem, as is the whole subject of susceptibility and idiosyn- 
crasy as much a mystery as ever. (6) The statistics of mortality 
relating to diphtheria are notoriously fallacious. Hospital records 
are, or should be, trustworthy, but they are not. As for the reports 
to societies giving the results of private practice, the majority of 
them are worthless. What do we think of physicians who report 
treating one or two hundred cases with but five or ten deaths ? They 
were probably nearly all cases of follicular tonsilitis. The thick 



SPECIFIC INFECTIOUS DISEASES. 55 

masses of white or yellow mucus which hangs from the naso- 
pharynx are often mistaken for diphtheritic membrane, and such 
cases are frequently reported as diphtheria. It is sometimes very 
difficult to diagnosticate diphtheria from scarlatina, for in the former 
we often see a scarlatinal rash, and in the latter the exudation closely 
resembles some forms of diphtheritic membrane. 

Treatment. — I advise the same isolation and antiseptic methods 
as recommended for scarlet fever. It is essential that the tempera- 
ture of the room be kept equitable between 75° and 80° F. The food 
question is a difficult one, on account of the great repugnance of the 
child to swallow anything. Milk must be given in some form, for 
it contains all the elements of nutrition. Malted milk, buttermilk 
or koumiss may be substituted. Meat juices are, in malignant cases, 
imperatively necessary. Domestic beef tea or broth is best, but 
Libby's beef juice, given in cold water, is excellent, and some of the 
peptonized beef preparations are good. Wine-whey made with Tokay 
is the best stimulant. Some physicians claim unusual success with 
alcohol or brandy. Dr. R. N. Tooker, who has had a large exper- 
ience in this disease, is a strong advocate of hyperstimulation in bad 
cases. 

Local Applications. — No one agent gives general satisfaction. 
One that seems efficacious in one case will fail in others. Alcohol 
diluted with equal parts of water, or more, or equal parts of aquae euca- 
lyptol, which I prefer, will in many cases arrest or decrease the exu- 
dation, and modify its malignant character. Chlorate of potash has a 
wide reputation, but has been abused. It has doubtless poisoned 
many cases, causing disease of the kidneys from which the patients 
never fully recovered. Jacobi, who is emphatic in his warning 
against it, says not more than thirty grains should be used (swal- 
lowed) during one day. I have discontinued its use except in mild 
cases. The liquor calcis chlor. advised by Neidhard is effective in 
mild cases, but is of no value in malignant cases. Permanganate of 
potash is of great value. It removes the foetor better than anything 
else, and is a most powerful germicide. Bromine and iodine never 
seemed to me to remove it. I have had signal success in several 
cases from gently brushing the throat, wherever the membrane was 
present, with a mixture of equal parts of tincture, ferr. chlor. and gly- 
cerine. It is very efficacious in preventing the recurrence of the 



56 THE PRACTICE OF MEDICINE. 

exudation after it has sloughed off. I think I saved my daughter's 
life by this means. 

Boric acid, while soothing and cleansing to the throat, is not 
powerful enough to destroy the septic poison, or disinfect the mem- 
branes. Eucalyptol is, I believe, one of our best agents to apply to 
the diseased surfaces. The methods of applying the selected agents 
are various, but, whichever is adopted, it should not be harsh. The 
sponge probe is not to be thought of. A soft camel's-hair brush can 
be used with safety. Gargling, except in adults, can rarely be ef- 
fectively practiced. In post-nasal cases it is of no value. The spray is 
gentle enough, but it cannot always be effectively used. Dr. Jacobi 
strongly recommends injecting through the nose, and in my experi- 
ence it is the only thorough and rational plan. An Alpha syringe 
that throws a continuous stream is the best instrument; with this, and 
a small nozzle or acorn-tip, a gentle douche of the whole post-nasal cav- 
ity and pharynx can be thoroughly accomplished. An atomizer throw- 
ing a continuous coarse spray is next of value. The antiseptic lotion 
should not be irritating, for the child will fear it and struggle so that 
the application can only be made by force and great expenditure of 
the patient's strength. For this reason, thymol, although a powerful 
antiseptic, is objectionable ; salicylic acid, etc., are equally so. The 
bichloride of mercury solution (1 to 3,000) has many friends who 
claim that it is very effectual as a douche, but the quantity used 
should be small. The cyanide and biniodide could be used, but in 
less strength (1 to 5,000). When the membrane is sloughing there 
is probably no remedy so powerful an antiseptic as peroxide of hy- 
drogen. It utterly annihilates the septic principle in pus as soon as 
it comes in contact with it, and prevents eroded surfaces from inoc- 
ulation. It can be used in fifteen- volume solution, but if large quan- 
tities are to be used it should be diluted with equal parts of distilled 
water, and injected through the nose. All applications should be 
made every few hours. 

The internal treatment should be based on the law of similia. 
The proof of this can be deduced from the results of the treatment 
of both schools, for all the medicines which have been found of any 
real value internally are capable of causing a similar condition, and 
nearly all are destructive to Loffler's bacilli. Although many cases 
begin with high temperature, neither aconite, gelsemium, veratrum 



SPECIFIC INFECTIOUS DISEASES. 57 

viride, nor any of the chemical antipyretics should be used. In a 
few cases only have I used veratrum viride, a few doses, with pleas- 
ant results. The fever is caused by septic material in the blood, 
and does not require antipyretics. Nor is belladonna useful except 
for a brief period before the exudation appears. Eucalyptus in 
material doses (one drachm to four ounces of water, a teaspoonful 
every hour) will do much to reduce the temperature safely. 

The mercurial preparations are equally praised by both schools, 
and both claim excellent curative results, with widely different doses. 
The " regulars " report a great many cases treated successfully with 
the bichloride in doses of one-tenth to one-sixtieth of a grain, re- 
peated every few hours, until the membrane is detached. They also 
report great success with the chloride (calomel) in doses of one to five 
grains every hour till its characteristic purgation appears. They have 
lately taken up mercurius cyanide, which they administer in doses of 
one-thirtieth to one-sixtieth grain, " until the membrane is detached." 
They deny any dangerous or even depressing effects from such doses. 
What shall we say? In law courts one man's testimony is consid- 
ered as good as another's unless he can be proved to be untruthful. 
Now, there are probably as many truthful men in each one hundred 
of the old school as in the same number in ours. We cannot ignore 
their testimony, or call it untrustworthy. I see but one explanation 
of this matter. It must mean that if a medicine is really indicated 
for a certain diseased condition, it will cure in any dose short of 
toxic. This conclusion is inevitable, for our school claims just as 
great success with the same mercurials in doses ranging from the 
one-hundredth to the thirtieth attenuation. Now, the " regulars " 
have no more right to deny the testimony of the homeopathic school 
than we have to deny their own, provided that those who testify 
know to a certainty that the disease they treated was diphtheria. 
Although the toxic effects of all the mercurials, particularly the 
iodides and the cyanides, present good pictures of the ravages of 
diphtheria, I prefer the cyanide, which I usually prescribe in doses 
of the hundredth of a grain every hour until I see some favor- 
able change. If such change does not appear in thirty-six or forty- 
eight hours it should be discontinued. The iodides are best indi- 
cated in " strumous " patients when contiguous glands are early 
affected. Next to the mercurials is kali bichromicum. The chief 



58 THE PRACTICE OF MEDICINE. 

diagnostic difference is that under kali the exudate is more tough 
and fibrous, and there is a tendency to croupous complications. I 
usually dissolve one grain of the crude drug or lx, in four or eight 
ounces of water, according to the age of the patient, and order a tea- 
spoonful every hour or two. Muriatic acid is useful in nearly all cases. 
When given strong enough to make water pleasantly acid it always 
affords relief to the patient, and exerts an excellent influence over the 
mucous surfaces. The " regular " school do certainly get favorable 
results from the tincture of perchloride of iron, but many of them 
believe that the benefit is mainly from the acid, and such is my con- 
viction. Phytolacca has always been a favorite remedy, ever since I 
first recommended it in the first edition of " New Remedies." It is 
useful in mild forms, when a stiffness and pain attends movements 
of the tongue or neck, and when the disease begins as a follicular 
amygdalitis, which, as Jacobi teaches, often forms a soil for the Lof- 
fler bacillus. I prefer the lx in frequently repeated doses. Year 
after year the newspapers teem with wonderful cures of diphtheria 
by means of crude sulphur applied to the membrane, but there has 
never yet appeared any favorable testimony for it from the medical 
profession. The laity always want to use it, and I always allow 
them to, but I have never been able to discover any beneficial action. 
If the heat of the body could evolve sulphurous acid from it we might 
expect benefit, for it is the acid alone that could be beneficial. This 
acid has been used with good results, according to several reports in 
the " Therapeutic Gazette " of 1889 or 1890. Apis mel. is certainly 
useful if rapid and extensive oedema of the throat and contiguous 
tissue appears, and I have seen good results from lachesis in some 
bad cases. 

The plan of applying to the membrane some digestive agent 
has been tried, and some success claimed for it. Trypsin was 
first suggested, and at that time I tested it in several cases. The 
membrane disappeared rapidly under its influence, but the patient 
died from auto-infection. Papayotin, the digestive principle of the 
papaya of the tropics, has lately come into use, and some good results 
have been reported. It may digest the exudation and the dead tis- 
sue, but it does not destroy the septic poison so as to prevent its 
absorption. I will suggest that its use be combined with that of the 
peroxide of hydrogen or eucalyptol. I have tried this method only 



SPECIFIC INFECTIOUS DISEASES. 59 

in one case, but it was one so fearfully malignant and rapid in its 
progress that I do not consider it a test. 

Next to diphtheritic croup, the complication most to be dreaded 
is heart-failure. In my early experience with diphtheria, before the 
importance of guarding against this accident was known, I lost sev- 
eral patients after convalescence was established. They were allowed 
to sit up and run around the room, when suddenly they would fall 
to the floor, and were dead before they could be taken up. This 
experience led me to always caution the attendants not to allow the 
child to be raised up in bed, or sit up, or to stand upon the feet, 
nntil I became satisfied that the heart was strong enough. Heart- 
failure occurs in diphtheria from various causes. Pericarditis and 
endocarditis are complications, and may lead to hydro-pericardium 
or valvular obstruction ; or a thrombus may form in the heart, a 
large clot, which may cause sudden death, or if small, may be pre- 
ceded by anxiety and dyspnoea. The heart should be examined 
every day, and if the pulse is feeble or irregular, cactus and nux 
vomica should be given. My own recent experience with tincture 
of cactus has taught me that in threatened heart-failure the dose 
must be larger than we have heretofore used. Recent experience 
with the tincture, and cactina (the active principle) have shown 
that heart-failure from paralysis is a secondary effect of the drug, 
as it is with digitalis and stophanthus. Primarily it causes death 
by contraction of the heart ; give then in feeble and irregular heart 
one drop of the tincture for each year of the child's age, and repeat 
it every half -hour, until the danger is past. In pulseless collapse 
give one-hundredth grain, or drop, of glonoine before giving the 
cactus ; one dose will arouse the almost dead heart, and allow time 
for the cactus to act. Nux vomica should be alternated with it — 
one-tenth to one drop every two hours. Cactina is more powerful 
than the tincture. A grain of the first centissimal trituration is 
equal to one drop of a good tincture. Digitalis and strophanthus 
are close analogues of cactus, and can be given in similar doses, but 
they are not as well borne by the stomach, being bitter and nauseous, 
while cactus is quite tasteless. Cactina is prepared by Professor 
Sultan of St. Louis, Mo. It can be used in tincture, or trituration, 
or can be injected hypodermatically. A condition of vaso-motor 
spasm of the pulmonary arterioles may set in suddenly, and threaten 



60 THE PRACTICE OF MEDICINE. 

life. This condition was first described by Dr. Richardson as " want 
of blood in the pulmonary circulation." The breathing is labored, 
although the lungs are full of air, and may be even distended with 
it sufficiently to produce in younger subjects a peculiar promi- 
nence in the anterior part of the chest. There is no sign of imper- 
fect aeration of the blood, but all the symptoms indicate obstruc- 
tion to the circulatory current. The lips and cheeks are blue, the 
jugular veins distended, the heart's impulse quick, feeble, and irreg- 
ular. The body is cold and pale ; it may be marbled, especially at 
the extremities, and there is intense anxiety and constant movement. 
The heart ceases to act before respiratory movements come to an 
end. In this condition, if urgent, a drop or two of amyl nitrite 
should be given by inhalation, or a drop of glonoine (one per cent) 
be placed on the tongue. This will relax the spasm of the arter- 
ioles. Then cactus lx or digitalis 3x should be alternated with vera- 
trum album, with intercurrent doses of glonoine if the circulation 
again becomes obstructed. Arseniate of strychnia 3x, a grain every 
six hours, should be given to prevent heart-failure, all through the 
disease. It will act as a prophylactic agent against the local par- 
alyses of the pharynx, soft palate, or muscles of accommodation of 
the eyes. If, however, these paralyses set in, gelsemium 2x will cure 
the majority of cases. If the limbs are paralyzed, strychnia phos- 
phate 2x, a grain three or four times daily, must be given until they 
regain their power. 

Cures of diphtheritic croup are so rare that it is worth while to 
put them on record when they do occur. 

Master D. S., ten years of age, was attacked on the 19th of No- 
vember, with sore throat. I saw him in the evening, and found the 
swollen tonsils covered with a loose, shreddy membrane. It had not 
the firm appearance of real membrane. Temperature 100°. Pulse 
80. Prescribed phytolacca and wash of boric acid. Twenty-four 
hours after, the throat looked very different. The posterior fauces, 
uvula, and arch of palate were partially covered with a pearly gray, 
firm membrane. The nose discharged an acrid secretion, and the 
nostrils were lined with a thin membraneous exudation. The voice 
was nasal, and he could not breathe through the nose ; no swelling 
of submaxillary glands. Mercurius cyanide was prescribed as fol- 
lows : a solution of one-sixtieth grain to one drachm of water, one 



SPECIFIC INFECTIOUS DISEASES. 61 

teaspoonful every four hours. The throat and nose were ordered 
sprayed with two per cent solution of Johnson's papoid ; and the five 
per cent solution in glycerine and water, equal parts, to be applied 
with a brush every half-hour. 

Nov. 21. The nose was more pervious, the membrane on the ton- 
sils appeared looser, showing the digestive effect of papoid. 

Nov. 22. All day the throat seemed to improve, but in the even- 
ing a suspicious croupy cough set in, with hoarseness. Kali bichro- 
micum lx was given in alternation with mercuric cyanide 2x, and 
the spray of papoid was used every half hour. 

Nov. 23. The symptoms all indicated that the diphtheritic mem- 
brane had invaded the larynx. The inspirations and expirations 
became difficult; the temperature increased to 102°. At 10 p. M. 
the breathing became so labored that I called in Dr. Pierce to 
decide on the operation of intubation. It was decided to wait until 
next morning. 

Nov. 24. Dr. A. B. Hale and Dr. Pierce saw him early, and 
the tube was placed. It gave much relief, and was worn until even- 
ing, when it was expelled during a fit of coughing, and with its 
expulsion came a large semi-tubular membrane, appearing to be 
partly disintegrated. A long, bent camel's-hair brush, soaked in a 
fifteen per cent solution of papoid, was pushed into the larynx in 
the hope of digesting the membrane, and the boy was made to inhale 
the papoid spray. All day he expelled pieces of loose membrane 
from the larynx. A tent was made to envelop the upper portion of 
the body, and into this tent was run a rubber hose, the outer end 
connected with the spout of a tea-kettle which was filled with lime- 
water. A constant vapor of this boiling lime-water was thrown into 
the tent. 

Nov. 25. The tonsils, fauces, and palate were free from mem- 
brane, the cough was loose and rattling, and the expectoration 
bloody and muco-purulent. The temperature did not rise over 101°; 
appetite good. 

Nov. 26. Continued improvement; aqua eucalyptol was added 
to the lime-water. The cyanide of mercury and kali bi chroma- 
turn were suspended, and sanguinaria nitrate 3x was given every 
hour. 

Nov. 27. Continued improvement. No membrane to be seen 



62 THE PRACTICE OF MEDICINE. 

on the vocal cords or in the larynx. The laryngoscope showed only 
a raw-looking surface. 

Nov. 28. From this date the improvement was rapid, but for 
several days the patient was kept in the tent inhaling the steam of 
eucalyptol in lime-water. One factor in this case greatly aided us 
in our treatment : the unusual and intelligent docility of the patient, 
who allowed us to do as we pleased with his throat. Had he been 
obstinate, and repulsed the applications, the case would probably 
have terminated fatally. Milk, beef extract (Libby's), and whisky 
were given freely. His voice is at times hoarse and whispering, at 
times clear. If no post-paralysis occurs, this case can be recorded 
as a marked cure of this most dangerous of all diseases. 

The conclusion seems warranted that most cases of diphtheria, 
when dismissed from treatment, still possess the capability of trans- 
mitting the disease. To determine whether this inference was actu- 
ally realized or not, twenty-one of the twenty-four cases were person- 
ally investigated with the view of learning if any, or how many, had 
been the focus of an epidemic. In only one instance was it found 
that a case had been the means of communicating the disease to 
others. While, perhaps, the likelihood of spreading diphtheria after 
convalescence from the disease is not great, the practical lesson 
taught by the study here outlined is that the greatest care should be 
exercised during this period, that the cases be not permitted to min- 
gle too soon with other persons, and that for a long time after the 
disappearance of the membrane and of all the symptoms of the dis- 
ease, the patients be instructed to continue the employment of anti- 
septic gargles. 

The question as to how long after the disappearance of the mem- 
brane the danger of contagion exists is one at once important and 
difficult of solution. In this connection, Tobieson ( Centralbl. f. 
Bakteriologie u. Parasiterikunde, xii. 17, p. 587) calls attention to 
the observation of Roux and Yersin that the bacillus of diphtheria 
may be found in the pharynx of persons that have suffered from the 
disease as long as five weeks after the disappearance of the mem- 
brane. The accuracy of this observation has been confirmed by the 
investigations of other authorities. To determine in what proportion 
of cases the presence of the bacilli persists after the disappearance 
of the membrane, Tobieson made examination in forty-six cases of 



SPECIFIC INFECTIOUS DISEASES. 63 

diphtheria in which the diagnosis had been established bacterio- 
scopically ; and found that in twenty-four the presence of bacilli 
could be demonstrated in the pharynx at various periods of time 
after the disappearance of the membrane. It was not found that 
the intensity of the attack bore any relation to the persistence of the 
bacilli in the pharynx, or to the lateness of the period at which they 
were found : neither did the existence of albuminuria exercise any 
influence in this connection : the existence of laryngeal involvement, 
and especially of nasal involvement, did, however, exercise a notable 
influence. In five of the cases, the presence of the bacillus was 
demonstrated microscopically and by cultivation ; in the remaining 
nineteen, guinea-pigs were inoculated with pure cultures of the 
organism obtained. Sixteen of the animals died, and presented 
characteristic manifestations. Two presented local swelling and 
pain, followed by necrosis : one of these died, but did not present 
the lesions of diphtheria ; the other recovered. One animal pre- 
sented local manifestations : after six weeks, paralysis of the hind 
extremities occurred, together with diarrhoea and emaciation. 



ERYSIPELAS. 

Definition. — " An acute inflammation of the skin, almost always 
involving the cellular tissue, originating for the most part in the 
neighborhood of wounds or sores ; attended with much redness and 
infiltration and severe febrile disturbance, and characterized by a 
marked tendency to spread over the surface and (especially in the 
presence of wounds) to become contagious. Erysipelas is either 
traumatic or idiopathic, i. e., it occurs in connection with wounds, or 
arises apparently spontaneously, on surfaces which were previously 
sound." I doubt if it is ever really idiopathic, i. e., arising de mtovo 
from within, when there is no lesion of the skin. Some authors say 
erysipelas of the face is generally idiopathic. I do not think so. 
Several years ago I had occasion to treat an unusual number of 
cases. It was during an epidemic of influenza in which the nasal 
discharges were acrid, and in many cases left a small crack or ulcer 
just inside the alae nasi. This crack was generally situated near the 
tip of the nose, and could be found only by opening the nostril and 
examining the fossae. In every case of erysipelas of the face, no mat- 



64 THE PRACTICE OF MEDICINE. 

ter where located, I found this lesion. Since that time I have care- 
fully examined the nose in every case of erysipelas of the face — and 
have always found it. This lesion is the gateway through which 
enters the streptococcus of this disease. I have known it to origi- 
nate in an excoriated external meatus of the ear ; in a crack of the 
lips ; and in an excoriated canthus of the eye. I do not deny that 
the coccus may enter the system through the mucous surfaces, as 
does the bacillus of diphtheria, and it seems to me that the explana- 
tions given under diphtheria are applicable here, namely : that the 
poison of erysipelas may fall upon mucous surfaces, be absorbed 
into the blood and cause the specific fever peculiar to the disease ; 
or, that it may enter some wound, or lesion of the skin, and cause a 
local inflammation confined to the region contiguous to the lesion. 
I therefore reject the division of traumatic and symptomatic. Hebra 
and Bristowe have the same opinion: that it is not a specific fever, but 
a local disease. The late Dr. Meiggs asserts in his " Midwifery and 
Diseases of Women," that puerperal fever is a true erysipelas, like 
the erysipelas of hospitals. This opinion is not now held by many. 
Yet it is well known that in hospitals where erysipelas is prevalent, 
the women in confinement have puerperal fever. This disease was 
once divided into vesicular and phlegmonous, but now the divisions 
are : simple, when only the cuticle is affected ; phlegmonous, when 
the subcutaneous connective tissue is involved ; cedematous, suppur- 
ative, or gangrenous, as the case may be, when it takes on either of 
those characters. It sometimes attacks serous membranes : thus 
erysipelas of the trunk may extend to the peritoneum, pleura, peri- 
cardium ; and to the cerebral meninges. It may extend to mucous 
surfaces, as into the ear, nose, fauces and vagina ; the veins, absorb- 
ents, and sympathic glands are often affected. When the infected 
area is on the skin there may appear, at short distance, isolated 
inflamed spots of the size of a quarter of a dollar, scattered here and 
there on the normal skin. These are sensitive to pressure, and are 
the foci of a new infection. 

I will not go into the aetiology, morbid anatomy, etc., of this dis- 
ease, but proceed to the principles of treatment. 

Treatment. — The fever, in case of local infection and inflamma- 
tion, does not set in until the blood has become poisoned ; then it is 
like any other septic fever. If it is taken into the system, as it 



SPECIFIC INFECTIOUS DISEASES. 65 

is in epidemic erysipelas, the fever begins before any local inflam- 
mation appears. The treatment will, therefore, depend upon the 
method of manifestation. If the constitutional symptoms appear 
first, we cannot always predict that they will lead to erysipelas, for 
the symptoms are such as usher in many diseases, namely : chills, 
fever, vomiting, headache, pain in limbs, high temperature, and 
quick, hard pulse. These symptoms would call for one of the fever 
trio : aconite, gelsemium, or veratrum viride. Veratrum viride 
seems to have some specific value in intensely inflammatory erysip- 
elas, aside from its influence in reducing the febrile heat. Dr. Wil- 
kinson and Dr. Drummond of England report many cases of ex- 
tremely violent character which were arrested by its use, internally 
and topically ; thirty drops were added to a half-pint of water, and 
constantly applied to the inflamed surfaces. At one time I used it 
locally, but stronger, and on antiseptic cotton or lint. It might be 
of benefit to add veratrum viride to an ointment of ichthiol. When 
locally applied to inflamed surfaces veratrum reduces the heat and 
redness. Dr. A. N. Banarji of India reports curing an erysipelatous 
inflammation of the calf of the leg with the gtt i. every two hours. 
As soon as the local inflammation appears, belladonna is called for 
in alternation with the fever-remedy selected, until the violence of 
the fever is subdued. Belladonna is almost the only remedy indi- 
cated in the red, smooth, phlegmonous variety. If it assumes a 
distinct vesicular character rhus tox., rhus radicans, or rhus venen- 
ata are better indicated. In phlegmonous cases accompanied by 
oedema, apium virus (apis mel.) should be given alone or with bella- 
donna. Sometimes cantharis, euphorbium, or lachesis may be 
found useful. I consider it important always to see that the bowels 
are unloaded, for I believe it is dangerous to allow foecal matter, 
saturated as it is in fever with ptomaines, to remain in the body. A 
few grains of mere, dulc lx followed by a bottle of congress water, 
or a few ounces of rubinat, or Hunyadi, is always advisable, except 
when diarrhoea has occurred. Lemonade, lime juice and water, but- 
termilk and skimmed milk, are the best beverages. Gruels made of 
wheatena, granum, sago, or gluten flour are sufficient food unless 
typhoid prostration calls for egg-nog, wine whey, beef tea, etc. 

Local Treatment. — When the inflammation enters through a 
lesion of the skin, or appears localized from general infection, top- 



66 THE PRACTICE OF MEDICINE. 

ical treatment is important. The early dogma of our school, that no 
local application should be made, has been virtually abandoned. 
There are two kinds of local treatment : one confined to the inflamed 
surfaces and its immediate surroundings ; the other to the surround- 
ing zone. Both have for their object, not a cooling or soothing influ- 
ence alone, but destruction of the coccus in the tissues. In the first 
method many drugs, as nitrate of silver, tincture of iron, and iodine 
were once used, but have been, or should be, abandoned, because 
they obstruct the pores of the skin. The application should be one 
that can be absorbed. Lotions of borax, boric acid, and pure alco- 
hol will answer in mild cases. Alcohol (absolute) has been found 
to arrest the inflammation. A weak (one per cent) lotion in water 
or alcohol, of creoline, ichthiol, resorcine, carbolic acid, and the 
bichloride of mercury, have each been highly praised. So have mild 
ointments of the same substances. I have had the best success with 
a one per cent of creoline, or a two to ten per cent of ichthiol- 
ammonia. In one case where an angry erysipelatous swelling 
appeared on the cheek of a child two years old, this latter ointment 
arrested it in three days. I consider ichthiol the best, though it 
should not be used strong enough to cause an eczema. Aqua euca- 
lyptol is excellent in the oedematous variety. When pustules begin 
to form, after the surface has vesicated, or if suppuration occurs, 
borated-calendula lotion, or " calendu-boric " powder should be ap- 
plied. Gilcrist (Arndt's " System of Medicine ") objects to carbolic 
acid and iodoform, when suppuration has occurred, and says : " Expe- 
rience has amply proved that calendula possesses these (antiseptic 
and germicide) properties in an eminent degree." Now, I object to 
this assertion, for experience has not proved it. As one eminent 
surgeon, Dr. J. C. McClelland, once stated at a meeting of the 
American Institute : " Calendula has not antiseptic properties 
enough to keep itself." An aqueous lotion of it, if allowed to stand 
in a warm place, will swarm with infusoria in a few hours. If used 
at all it should be combined with boracic acid, when it becomes the 
best application to wounds we know of. The other local treatment 
consists in applying something that will cause compression on the 
zone around the inflammation in order to limit the migration of cocci 
into the surrounding tissues. Strips of adhesive plaster will do this. 
I have applied them to the forehead tightly, and prevented inflam- 



SPECIFIC INFECTIOUS DISEASES. 67 

mation from spreading into the scalp. Collodion is useful. If the 
collodion is made with two per cent ichthiol it is more effica- 
cious. Methyl blue has lately been advised as even more effect- 
ive. When isolated red spots — new foci — appear, the ointment, or 
collodion, should be made to cover the whole of each spot and an 
inch beyond, or as far as the tenderness is shown on pressure with 
the finger. In surgical erysipelas some authorities recommend scari- 
fying the zone only skin deep, then after washing the surface with 
some antiseptic lotion, applying the ointment to the scarified surface, 
rubbing it well in. 

I have not mentioned many of the medicines recommended for ery- 
sipelas in our text books, because I believe the symptoms given are 
of little value. Comoclodia is but little used, yet it is a more viru- 
lent poison to the skin than rhus. Ledum is of some value when 
the bites of insects cause an erysipelatous swelling ; also arnica. I 
have cured a few malignant cases with lachesis. Pulsatilla is of 
little value. Terebinth is useful when large bloody bullae appear. 
Graphites and ptelea are of real value in chronic erysipelas, when 
the slightest irritation of the skin makes one liable to an attack. 
We get this curative action by an influence they possess to alter 
the constitution of the blood. 



LA GRIPPE — (Epidemic Influenza). 

Definition. — Dr. Julius Althans of London, whose opinion seems 
to me the nearest correct, asserts that this disease is 4 * not a catarrh 
but an infectious neurotic fever." He refers all the symptoms to 
" irritant poisoning by a grippal toxine on different centres of 
nervous force in the medulla oblongata." He attributes the pecul- 
iar fever to congestion of the thermolytic (heat) centre in the bulb, 
by the irritant effect upon it of this " grippal toxine." The other 
symptoms of the nervous form of grippe were similarly referable to 
various centres in the bulb. Grippal catarrh with pneumonia is due 
to congestion and inflammation of the nuclei of the fifth pair and 
the vagi accessorii in the bulb. The hemorrhagic tendency is caused 
by a congestion of the vaso-constrictor centre in the bulb, and is 
occasionally transmitted to the splancnic nerve by anastomoses in 
the cardiac plexus, and might then cause symptoms of dysentery or 



68 THE PRACTICE OF MEDICINE. 

choleraic diarrhoeas. Dr. Pferffer of Vienna, and others, claim to 
have discovered the bacillus of the grippe. The one chief charac- 
teristic is that " it is the smallest bacillus yet discovered." Pfeiffer 
has inoculated animals with the cultures, which caused in them all 
the prominent symptoms of the disease. 

The infection is supposed by some to arise from the secretions of 
the nasal passages, but this can hardly be, for many cases have no 
discharge whatever. The grippe bacillus must enter the blood as 
does the bacillus of malaria. In fact these two bacilli have many 
effects in common. Both are protean in their manifestations ; hardly 
an organ or tissue escapes their ravages ; they poison the brain, spinal 
cord, and the whole nervous system ; the whole extent of the mucous 
surfaces ; the lungs, liver, heart, uterus, ovaries, muscles and glands ; 
and Dr. Savage ascribes to them many forms of mental alienation. 
Like the cholera, the grippe had its origin in Central Asia ; some 
say in Afganistan. Thence it spread to Persia, Russia, and other con- 
tinental countries, then to England, and finally to the two Americas. 
The symptoms are so multitudinous that I will not attempt to enu- 
merate them. We have all witnessed them during three winters, 
1889, 1890, and 1891, and shall probably see them for several years 
yet, for the disease has now come to stay. There is no special or 
unvarying treatment. We know of no specific, and so we cannot 
destroy the pervading bacillus by any known drug; we can only treat 
its various manifestations. I can give but the principal remedies that 
have been found most useful in the practice of both schools, and add 
thereto my personal experience and observation. Among these drugs 
are gelsemium, iodide of arsenic, napthaline, camphor, belladonna, 
hyoscyamus, phenacetine, salicylate of soda, salicine, nux vomica and 
strychnia, manaca, eupatorium perf ., rhus, and zinc. Gelsemium has 
probably been oftener and more successfully used by homeopa- 
thists than any other drug, in the usual or commoner forms, when 
the catarrhal and influenzal symptoms were prominent. I will quote 
an old school authority, and while he doubtless gained his informa- 
tion from our works, his testimony is valuable. Dr. John Aulde 
declares it superior to all other remedies. He says : " Gelsemium 
arrests profuse nasal secretions, quiets headache and neuralgia, sub- 
dues cough and pain, favors the re-establishment of the secretions 
through its influence on the skin, kidneys, and gastro-intestinal 



SPECIFIC INFECTIOUS DISEASES. 69 

tract. It reduces temperature and pulse rate, promotes sleep, and 
creates a feeling of comfort and well-being without in any way 
approaching narcosis, or destroying the oxygen-carrying capacity of 
the blood corpuscles, . . . and the recovery is prompt, perfect, and 
satisfactory in every particular." He advises ten drops put in three 
ounces of water, a teaspoonful of this every ten or fifteen minutes 
for an hour, then at less frequent intervals. I will add that it 
removes the intense aching and soreness all over the body, and in 
children prevents all spasmodic symptoms. 

Eupatorium perf. is excellent for similar symptoms, when there 
is added to them acute bilious derangement. Iodide of arsenic is 
specific when the catarrhal symptoms are intense, when the nose, 
eyes, and throat are most affected, and the discharges are very acrid 
and irritating ; phosphorus, when the bronchi and lungs suffer most ; 
nitrate of sanguinarina, when the tracheae and larynx are affected ; 
napthaline, when the symptoms simulate hay fever, and the dis- 
charges are profuse and unirritating. Merc. iod. and kali iod. often 
do good service, when ars. iod. does not control the intense coryza 
and other influenzal symptoms ; camphor, when the virulence of the 
poison causes a collapse of the vital forces, with or without choleraic 
symptoms. Phenacetine is invaluable when pain, general or local, 
is the symptom most complained of. It is almost indispensable, and 
there are but few manifestations of pain that it will not alleviate. 
In children doses of a fraction of a grain will suffice. In adults it 
may require three, five, or ten grains every hour or two to give 
relief. In such cases it is not dangerous. I have never seen un- 
pleasant effects. 

La grippe often simulates rheumatism very closely. Then the 
salicylate of soda in doses of three grains every hour relieves quickly. 
Salicine comes next in order, and is highly praised by some who 
claim that by " saturating the system " with it, giving ten to fifteen 
grains every hour, salicine destroys the bacilli of grippe, as does qui- 
nine those of malaria. In the few cases in which I used it, it acted 
favorably. Manaca is indicated when the chief suffering is in the 
head and joints, which "feel as if bound tightly by an iron band." 
A teaspoonful added to a glass of water, a spoonful every half -hour, 
is the proper dose. Rhus tox. is the remedy in many cases when 
given for its well-known indications. Nux and strychnia are useful 



70 THE PRACTICE OF MEDICINE. 

in the paralyses which sometimes follow. Aurum, especially the bro- 
mide, relieves many of the mental disorders, particularly despond- 
ency, melancholia, suicidal mania, and in children, epileptiform 
attacks ; anacardium, for the mental hebitude, which is often a 
sequel. In a few cases, when the local pain in the stomach, bowels, 
ovaries and uterus was unbearable and obstinate, I have injected a 
combination of morphia and atropine (one-eighth grain of morphia 
and one-hundredth of atropia) as a temporary relief. It is some- 
times necessary to use it. 

During the winter of 1892 there seemed to be, judging from the 
reports of the Chicago Board of Health, an unusual number of cases 
of typhoid fever. From my own experience I did not believe that 
the reports were correct. In a communication to a morning paper I 
explained that a large proportion of the cases reported were grippe 
fever. I said : " Typhoid fever is always due to a specific bacillus 
found in drinking-water. The patient is infected by drinking impure 
water in which this bacillus is found. As there are no wells in this 
city, it must be in the lake water contaminated by sewage or surface 
water. Grippe fever is a neurotic form of the grippe, and if it is a 
bacillus it must contaminate the public through the medium of the 
atmosphere, as in case of measles and scarlet fever. Typhoid fever 
is due to the presence of a poisonous bacillus in the intestines, where 
it causes a specific ulceration of Peyer's glands. The blood finally 
becomes infected. The fever itself, or the abnormal heat of the 
body, is due to a septic material in the circulation. The heat in 
grippe fever is due to a specific poison, affecting the heat-producing 
centres in the medulla. Typhoid fever comes on gradually with 
prostration, generally diarrhoea, with little or no pain except a dull 
pain in the head. Grippe fever attacks the patient suddenly with 
violent pain all over, at least for a few days. There is rarely a 
diarrhoea and no intestinal lesion. The duration of both fevers is 
about the same, fourteen or twenty-eight days. In typhoid fever the 
pulse is always in accord with the febrile heat, i. e., if the heat is 
105° F., the pulse is 120 or 130 per minute. The pulse in grippe 
fever is usually below the rate which we expect the pulse to be at 
that temperature. I have often seen the pulse 80 or 90 when the 
temperature was 104° or 105°. The pulse has this peculiarity in 
brain fevers and cerebro-spinal fevers, and in no other except the 



SPECIFIC INFECTIOUS DISEASES. 71 

grippe. I suspect there is a family relationship between grippe 
fever, meningitis, and cerebro-spinal fever. I am informed that in 
Indianapolis this winter the grippe has assumed the form of cere- 
bro-spinal meningitis, many cases of which were fatal. A few such 
cases have occurred in this city. I found that this form was best 
treated with belladonna and zincum. Among the sequelce of grippe 
none are more obstinate than the profound nueraesthenia, with great 
physical prostration. This is best treated by hydrastia mur. (white 
alkaloid) combined with hypophosphite of soda. The obstinate ver- 
tigo is relieved by ergot (ten to thirty drops three times a day ; or 
zinc phosphide tablets ot the 2x four times a day). 

For the aphonia, especially of singers and public speakers, give 
causticum, or use the mild faradic current. Impotence in both sexes 
is removed by sabal serrulata, aurum mur. et sodii, and the faradic 
current. 

La grippe sometimes leaves the patient with a sub-normal tem- 
perature which may last several weeks. I had several cases in which 
it ranged from 96° to 98°, rarely reaching normal ; yet the patients 
did not feel ill. Cocculus and zinc phosphide cured. In many 
other cases one of the sequelce was a slow pulse. In one case under 
my care it remained several weeks at 42. Another had a pulse of 40 
lying, 50 sitting. My own pulse for a week was 56, In all cases 
it was regular. Cactus lx, ten drops every four hours, restored the 
heart to the normal rate. Some required strychnia, and one san- 
guinaria. 

A physician at the head of one of the largest hospitals in Chi- 
cago reports that this disease seemed to increase the severity of all 
our epidemic maladies. He observed, following the epidemic, many 
cases of continued fever which had been admitted to hospital classi- 
fied as typhoid. He soon began to doubt the diagnosis. A study of 
fifty cases had afforded the following data : No common cause could 
be assigned. Previous history was negative. Some had had grippe, 
but the majority not. The prodroma lasted four days, with extreme 
muscular soreness. The onset was gradual, no chill being noticed, 
but the fever was continuous without intermission. The average 
dura was twenty-three days. Relapses were common, but could be 
attributed in many cases to dietetic errors. There were no head 
symptoms or coma, and no subsultus. In four cases there was pro- 



72 THE PRACTICE OF MEDICINE. 

fuse sweating, lasting over ten days. The stomach was not trouble- 
some. Secretions were all diminished, and there were not cutical 
discharges. The mouth was rarely dry, tongue not fissured, and no 
sordes. The dorsum was milk-white. There were no tympanitis or 
abdominal tenderness ; no peritonitis, while the bowels were bound 
up. In only three cases did the stools suggest typhoid. No bac- 
teria were found in the stools. The urine did not respond to the 
Ehrlich test, nor were any albumen, sugar, or casts found. There 
was no rash. He did not believe that the disease was typhoid. In 
treating the cases main reliance was placed on sponging and packs. 
Three cases died, one from pneumonia and two from exhaustion. 
No intestinal lesions were found at any of the autopsies. 



WHOOPING COUGH. 

Definition. — An infectious specific disease, chiefly of childhood, 
in which catarrh of the air passages is combined with nervous symp- 
toms. It is divided into three stages, not very sharply separated 
from each other: the catarrhal stage, lasting from ten to twenty 
days ; the spasmodic stage, sometimes lasting thirty to forty days ; 
and the stage of remission, or decline, which may last three weeks 
or three months. The complications are bronchitis, pneumonia, 
emphysema, collapse of lung tissue, convulsions, hydrocephalus, 
apoplexy, laryngismus stridulus, hemorrhage, marasmus, strabismus, 
and remittent fever. The stage of incubation varies from five to 
ten days. Sporadic cases in isolated regions often occur. The exact 
nature of the contagious principle is not yet placed beyond a doubt. 
Letzerich supposed it to be fungus ; Bouges believed it to be a 
micrococcus. Dr. Afanasief has lately succeeded in cultivating 
what he believes is the bacillus of whooping cough. Injected into 
animals, it developed symptoms closely simulating this disease — 
even the post mortem appearance was the same. Although gener- 
ally confined to children, I once treated two cases in old women aged 
respectively seventy and eighty. It must have been more fatal for- 
merly, for, according to Hirsch, " 72,000 persons perished from this 
disease in England and Wales, between 1848 and 1855, or 1 in 
every 40 who died." Even now the rate of mortality is too high. 



SPECIFIC INFECTIOUS DISEASES. 73 

If a bacillus is really the cause, an inoculation of the proper culture 
ought to prevent or modify the disease. 

Treatment. — As it now stands, the treatment for this disease is 
the opprobrium of all medical schools. It is not an exaggeration to 
say that hundreds of drugs have been used for it, and not one can be 
said to be specific. One may seem to be curative in one epidemic, 
while it will fail in others. Drosera, so highly praised by Hahne- 
mann, especially in the convulsive stage, and in the thirtieth, has 
disappointed me in any attenuation. Eclectics lately claim good suc- 
cess with it in doses of five drops of the tincture every three hours. 
It is an excellent remedy for a night cough, worse on lying down, 
and of a shaking character, but I have never known it to" cut 
short " the convulsive stage. Xeither have I seen such magical 
effects as Teste claimed for corallium rubrum, in either the 30th or 
3x, although I have been assured by mothers that wearing coral 
beads will modify the severity of the paroxysms. I am sorry to 
record this experience, but I am not writing this book to repeat 
parrot-like the recommendations of others. I wish to record actual 
results. In the first or catarrhal stage, especially if attended by a 
remittent fever, gelsemium has acted satisfactorily. It shortens this 
stage, and modifies the convulsive. Belladonna certainly is of ben- 
efit in some epidemics. "When the convulsive stage begins, the throat 
is red and dry, the congestion of the head is notable, and causes the 
eyes to be blood-shot and the pupils to dilate. There is no expec- 
toration, and the cough is worse nights. The old school a few 
years ago considered belladonna almost specific ; they gave it to the 
verge of toxicity : then they praised atropine for a time ; but rarely 
is either mentioned now. I have to record that I have had more 
satisfactory results from ipecac and hyoscyamus, alternated or com- 
bined, than with any of our remedies. A drop of the tincture of 
each gives the best results, repeated every two hours. However, if 
this does not modify the cough in a week, it should be suspended. 
One of the best palliatives for the harassing day or night cough, 
which precedes, attends, or follows the convulsive stage, is Auber- 
gier's syrup of lactucarium (lettuce). A chemist recently asserts 
that this plant contains hyoscyamine. On referring to the patho- 
geneses of lactuca virosa, you will find that the symptoms closely 
resemble drosera and hyoscyamus. A good tincture of the fresh 



74 THE PRACTICE OF MEDICINE. 

plant acts well in doses of five or ten drops. The virtues reside in 
the milky juice. The dose of the syrup is a teaspoonful every two 
hours. I have seen good effects from cuprum when convulsions 
threaten and the fingers and feet contract forcibly, with stiffness of 
the whole body, and suffocative attacks caused by spasms of the 
chest. 

These are the chief remedies of our school which I have found of 
value. I do not ignore the fact that drosera and corallium may have 
been useful, but the genius of epidemics change ; and these drugs 
may again be useful in future epidemics. About the time Dr. 
McGruder recorded his experience with Gold (quoted by Dr. Wood, 
from "Journal of Obstetrics"), I had several cases in which the 
" whoop " ended in laryngisnus stridulus. I found the exact simil- 
imum in the pathogenesis of aurum, and gave it in the 3x with good 
results. In another epidemic I have lately had excellent results 
with the bromide of gold in the 3x, giving two grains three times 
daily. I believe this preparation will be found the best. In obsti- 
nate cases I have not hesitated to try other drugs. The oxalate of 
cerium, has been of value when the spasmodic cough so irritated the 
stomach that all the food taken was vomited. It certainly arrested 
the symptoms when given in doses of one to five grains several times 
a day. In a few cases when the paroxysm came only at certain 
hours of the day or night, quinine seemed to effect a favorable change. 
Dr. Griffith's favorable experience with antipyrin is worthy of atten- 
tion. Sonnenberger had the same favorable results. Both report 
that in several severe epidemics they began its use in the catarrhal 
stage and continued it into the spasmodic, giving from one-seventh 
grain in young children to five or ten grains in older children or 
adults, three times a day. The paroxysms were reduced to five or 
six a day, and the disease was entirely cured in three to five weeks. 
Other observers have lately confirmed this experience. In a few 
cases I used the 2x trit. in five-grain doses with good results. It 
must be borne in mind that in certain persons small doses of anti- 
pyrin cause unpleasant symptoms, and it should be used with cau- 
tion. Sonnenberger, however, did not observe any bad effects in 
any case. Other authorities report similar good results with acetane- 
lide, used, however, in smaller doses, varying from one-tenth to three 
grains every six hours. I have not used it, but I have used phe- 



SPECIFIC INFECTIOUS DISEASES. 75 

nacetine with favorable results, not only modifying the neurotic ele- 
ment of the cough, but acting as a general sedative. It is much 
safer than either antypyrin or acetanelide. It controls the nervous 
erethism that often precedes convulsion, prevents irritation of the 
brain, and causes the child to sleep naturally. The dose is from two 
to ten grains of the lx for young children and three to five grains 
of the crude drug to adults, repeated every three or four hours. 
Terpene has been used by Talamon (" Medicine Moderne," 1890), 
with gratifying results. "Children can take five grains three or 
four times a day. It diminishes the violence and duration of the 
paroxysms, and hastens the cure of the concomitant bronchitis. It 
acts as a calmer of the nervous system, modifies and removes the 
bronchial secretions. It has also antiseptic properties which enable 
it to act, not only on the symptoms, but on the whole cause of the 
cough." I have found it to act best when the bronchial secretions 
were very profuse and clogging, but smaller doses should be used. 
A few grains of the lx trit., or one grain in syrup every three or four 
Jiours, is sufficient. Acting on the theory that it is a bacillus which 
causes the cough, vapors, sprays, and powders containing antiseptic 
agents have been used with varying results. 

Bromoform has been sucessfully used. It lessens the violence 
of the paroxysms, and shortens the duration of the disease. It has 
anaesthetic powers like chloroform, from which it differs only in that 
the three atoms of chlorine are replaced by three of bromine. The 
dose is one or two drops for each year of the child's age, repeated 
every two or four hours. It is best administered in syrup and gly- 
cerine, the dose diluted with a teaspoonful. During the treatment 
there is a marked absence of bronchial irritation. Some of the most 
violent cases complicated with pneumonia are quickly benefitted by 
it. One of the most remarkable claims is that made by Dr. Mohn 
(in " Maladies de l'lnfance " May, 1888). He states that he has in 
a number of cases produced immediate and permanent cures of 
whooping cough by fumigations with sulphur. He proceeds as fol- 
lows : "In the morning the children are clothed and removed from 
their sleeping rooms in which are hung all the clothing, toys, and 
everything the children use. In this room about four ounces of sul- 
phur for every cubic yard of space is ignited, and the sulphurous acid 
allowed to remain in the room about five hours. The room is then 



76 THE PRACTICE OF MEDICINE. 

well aired, and the next evening the child sleeps in the room and 
bed, which is completely disinfected." It is said that a cure is at 
once produced. Others recommend burning small quantities of 
sulphur on live coals in the room while the children remain there. 
The fumes should be strong enough to irritate but little the throat 
and nasal passages. The vapor of cresoline has been quite popular. 
Turpentine embrocations to the chest, a spray of two per cent solu- 
tion of resorcine, and, latest of all, a draught of an infusion of thyme, 
are highly recommended. All these may be useful in some cases. 
Even change of air, if only to a few miles in the country, often cures 
the cough. Various methods have been recommended to arrest the 
paroxysm itself. Drs. Simpson and Churchill used chloroform, and 
claimed good effects in modifying the spasms, and even the whole 
malady. But in the "Journal de Medicine," Paris, 1890, Dr. 
Naegeli says that in more than five hundred instances he has appar- 
ently arrested the spasm of whooping cough by pulling the lower 
jaw downward and forward. He states that the result of the pro- 
cedure is not due to psychic influence, for this method succeeds even 
during sleep. He asserts that the suppression of the paroxysms 
exerts a good effect on the progress of the disease. 



PAROTITIS. 
There are two forms of parotitis, the idiopathic and symptomatic. 

IDIOPATHIC PAROTITIS — (Mumps). 

Definition. — An acute, febrile, contagious disease, characterized 
by an inflammation of the salivary glands, especially the parotid, 
with a marked tendency to secondary inflammation of the testicles 
in the male, and of the vulva, ovaries, and mammae in the female. 
It is said to be communicable before the glands are affected. The 
period of incubation varies from eight days to three weeks ; the dis- 
ease occurs but once in the same person. 

The above is generally accepted as correct, but I object to the 
term " secondary," because there are cases in which the testicle is 
affected before the parotid. No mention is made of a possible metas- 
tasis or extension of the inflammation to the brain or its membranes. 



SPECIFIC INFECTIOUS DISEASES. 77 

I am confident that in two children I saw the hard red swelling of 
the gland subside, and meningitis followed soon after with convul- 
sions, coma, and death. 

J. Lewis Smith mentions the curious fact, which I have twice 
observed, that a person may have the disease on one side only, and 
after several years have parotitis on the opposite side. The sub- 
maxillary and sub-lingial glands may be the sole focus of the infec- 
tion. In severe cases there is swelling of the tonsils, and oedema of 
the sub-mucous tissue of the pharnyx. Sometimes the pain and suf- 
fering is very great, and deglutition almost impossible. In rare 
cases an abscess forms, discharging outwardly or into the auditory 
meatus. I was cognizant of one case in which enormous enlarge- 
ment and permanent induration resulted. In some instances, dur- 
ing the interval between the subsidence of the swelling and the sec- 
ondary inflammation, alarming symptoms of collapse and cerebral 
irritation may appear ; the face is pale, the pulse greatly accelerated, 
with high temperature ; delirium, vomiting, and purging may occur. 
Laird does not think this is due to metastesis to the meninges 
44 because the symptoms promptly disappear when the external swell- 
ing is redeveloped." But if it does not, and the patient dies ? 

Treatment. — The diet should consist of liquid food, milk, and 
gruel during the fever, and broth after. Warm, never cold, appli- 
cations should be used. An ointment of belladonna or phytollacca 
externally, and the same medicines internally, are the most efficient 
remedies in nearly all cases. If the pain in the gland extending into 
the neck, shoulders, and head is very severe, phenacetin in doses 
of three to five grains every hour or two will give relief, and prevent 
meningitis. If pain and distress in the heart occur give cactus and 
spigelia. If collapse sets in, glonoine will quickly bring about reac- 
tion. In scrofulous children, mere. iod. may be needed, followed by 
hepar sulph. silica, or calc. hypophos. As soon as fluctuation ap- 
pears, use the lancet. In cases of induration, conium, baryta iod., 
and inunctions of an ointment of uvedalia will generally soften and 
reduce the swelling if recent. For metastisis to the testicles, ovar- 
ies, and breasts, aurum, conium, and phytolacca. Salol, in doses of 
five to ten grains every two hours, has been highly recommended in 
parotitis on account of its supposed relation to rheumatism. I have 
not used it. 



78 THE PRACTICE OF MEDICINE. 



SYMPTOMATIC PAROTITIS. 

Definition. — A secondary affection, not communicable, and has 
no tendency to involve the mammae, testicles, or ovaries. Unlike 
mumps, it generally ends in suppuration. It is generally a sequel 
of typhoid, diphtheria, dysentery, pyaemia, and the eruptive fevers. 
It may attend erysipelas and ulcerative diseases of the throat. In 
many respects it resembles a form of mastitis, which is supposed to 
be caused by toxic bacteria entering the gland through the nipple. 

Treatment. — If seen in the early stage, we may be able to secure 
resolution by means of phytolacca internally and externally applied. 
If suppuration threatens, give hepar sulph. and silica. If pus forms> 
use the lancet, under antiseptics. 

Since the above was written I have treated a case of mumps 
which possessed peculiar interest. A well-developed girl of twelve 
had a not large swelling of the right parotid, which subsided on the 
fifth day. On the seventh she was attacked with intense nausea, 
vomiting, and headache, with swelling of the maxillary glands on 
both sides. This lasted for four days, when she complained of 
severe aching pains in the lower abdomen, not specially located in. 
the uterine or ovarian regions. Pressure on the ovaries caused no 
pain ; two days after, the menses appeared (for the first time), 
scanty on the first day and natural after, both in quantity and dura- 
tion. As soon as the flow appeared all the other symptoms subsided. 
The left parotid was not affected. The medicines used were Phyto- 
lacca and pulsatilla. 



CARBUNCLE. 

Definition. — A local phlegmonous inflammation with deap-seated 
pain, terminating in abscess, or a nest of abscesses, and leaving a 
cicatrix. It differs from the boil in that there is generally a num- 
ber of openings. Simple carbuncle differs from anthrax, which 
originally attacks cattle, and is known as " murrain " and " char- 
bron," and is caused by a specific bacillus, while the former is caused 
by a micrococcus. 

Carbuncles in most cases attack the back of the neck, but they 
sometimes appear on the shoulders, back, and buttocks. I have 



SPECIFIC INFECTIOUS DISEASES. 79 

known several on the back of the head. I believe the collar, irritat- 
ing with its rough edge, is the cause of the location of carbuncle on 
the neck. Women rarely if ever have them there. 

Treatment. — Internally the same treatment as for boils, except 
when the inflammation is extensive and erysipelatous or oedematous, 
when belladonna, arsenic, apis, lachesis, and mygale are useful. 
Arsenic is probably the best constitutional remedy. The real anthrax 
is a very dangerous disease, and carbuncle often kills the old and 
debilitated, especially those who have long indulged in alcohol and 
malt liquors. If absorption of pus occurs, the most vigorous tonic 
treatment is required. The local treatment is to be conducted on 
the same principles as for erysipelas and boils. The carbolic acid 
should be injected in every nodule, or pustule, on or around the 
central inflammation, and the needle should be pushed deep into the 
swelling. This, in an early stage, will prevent suppuration. If we 
do not see the case until suppuration has occurred, the pus should 
be drawn out by an aspirator, or evacuated by the knife, and the 
cavities and honey-combed tissues thoroughly syringed out with 
hydrogen peroxide, five or ten volumes, and then with carbolic acid 
(ten per cent) or a saturated solution of pyoctanin. This treatment 
is better than poulticing or incisions. Compresses of lint, saturated 
with borated calendula, a solution of pyoctanin, or permangonate of 
potash are better. 

In a paper read before the Academy of Medicine at Paris, Dr. 
Allison of Baccarat recommends the simultaneous internal and 
external employment of boric acid as a simple and efficacious treat- 
ment of furunculosis. He considers the carbolic acid spray, cor- 
rosive sublimate baths, and analogous means, well enough suited 
to hospital use, but difficult of application in private practice. The 
author's method, as reported by Sem. Med., consists in administer- 
ing, for a week to a fortnight, eighty centigrammes (twelve grains) 
of boric acid daily, in two wafers. At the same time he applies 
externally, by gentle friction, a four per cent aqueous solution of 
boric acid, warm, four or five times a day. In the intervals between 
the frictions, compresses saturated with the same solution are applied 
to the affected parts. It is claimed that this treatment will abort 
furuncles yet in the commencement of developments, rapidly cure 
those already arrived at maturity, and prevent new eruptions. The 



80 THE FEACTICE OF MEDICINE. 

author considers the boric acid medication equally efficacious in 
anthrax. He has obtained a great improvement both in the local 
and general condition ; the pain, peripheral redness, and hardness of 
the anthrax diminish ; numerous apertures rapidly form for the elim- 
ination of the core ; the fever falls, excitation and insomnia abate ; 
and the anthrax heals, in the majority of cases, without surgical 
interference. 

TETANUS. 

Definition. — This disease is now believed to be caused by a 
bacillus, which has been isolated, cultivated, and has caused tetanus 
when injected into the blood of healthy animals. Breiger separated 
from the culture of this bacillus and from subjects dead of tetanus, 
three poisonous substances. They are ptomaines : one, tetanin, 
causes all the characteristic symptoms of tetanus ; another causes 
tremors, convulsions, and subsequently paralysis ; and a third causes 
at once intense clonic and tonic spasms. The tetanus bacillus is 
found in most kinds of dust and dirt, and in the manure of stables. 
Pathologically, the malady is supposed by a few authorities to be an 
inflammation of the gray matter of the cord — a central myelitis. 
There are two varieties, the idiopathic and traumatic, but as the 
symptoms are the same, and the same bacilli present, there is no 
need of separating them. Several drugs have the power of causing 
tetanus, or a condition very closely simulating it. 

The first sensations of tetanus are felt about the throat, causing 
difficulty in swallowing ; then a pain in the epigastrium, extending 
to the back, owing to spasms of the diaphragm ; the muscles of the 
jaws are affected, causing trismus. Then it extends to the trunk, 
causing opisthotonus, emprosthotonus, and general stiffness. Spasm 
of the glottis may occur, causing asphyxia. One variety, Rose's head 
tetanus, resembles hydrophobia, and is caused by injury to the fifth 
nerve. One notable symptom is always present, caused by an in- 
tense hyperesthesia of the reflexes — namely, that the slightest con- 
tact, the shutting of a door, or any jarring noise, the touch of the 
bed-clothing, even the contact of the air, as in fanning, will excite 
the convulsive paroxysms. The mind is usually clear till death. 
The temperature is very high, reaching 110° or higher. Death 



SPECIFIC INFECTIOUS DISEASES. 81 

usually takes place from apnoea. A slight wound, a foreign sub- 
stance, a needle or a nail, forced into the tissues, may cause an 
attack of tetanus. It was once supposed that an injury to a nerve, 
causing inflammation, was transmitted back to the spinal cord, but 
this has been abandoned for the theory that the bacilli is introduced 
into the blood through the wound. Next to the traumatic causes, 
exposures to cold and wet are the most common causes. This is the 
exciting cause of nearly all the cases of idiopathic tetanus. A kind 
of tetanus is supposed to be caused by intestinal parasites ; another 
to be excited by labor, abortion, and operations on the womb. In 
newly-born infants it is caused by inattention to the severed umbil- 
ical cord. 

Hammond gives an excellent resume of the old-school treatment. 
By this it appears that calabar bean, chloral, bromide of potassa, 
Indian hemp, and chloroform are the most successful. Dr. Yandell, 
commenting on the treatment of a large number of cases of which 
he has collected the data, says : "No agent has yet established its 
claim as a true remedy in tetanus." 

Hammond says he has treated three cases successfully with large 
doses of cannabis indica and ice-bags to the spine. He expected to 
find in " woorara " a curative agent, but it failed. 

" Hypodermic injection of one-sixth grain of carbolic acid every 
two hours for seventeen days cured a case of traumatic tetanus after 
chloral and bromide of potash failed." ("Archive de Medicine," 
1891.) 

Hypodermic injection of antifebrin has cured several cases of 
tetanus traumaticus. Two cases of traumatic tetanus have been 
cured by paraldehyde ; dose, one hundred and fifty minims a day. 
Pilocarpin injections cured three cases due to a wound. Urethan is 
supposed to have cured one case. These citations are from Euro- 
pean sources. Dr. J. Martin Kershaw, of St. Louis, in his article 
in Arndt's " System of Medicine," narrates a case of traumatic 
tetanus cured by gelsemium, fifteen drops in one-half glass of water, 
a spoonful every two hours. In my monograph on gelsemium writ- 
ten in 1862, I predicted that tetanus could be cured by it, but the 
above is the only one yet recorded in which it was used alone. 
Kershaw recommends belladonua, cicuta, conium, lachesis, physo- 
stigma (calabar bean) phytolacca, and stramonium ; but no cures 



82 THE PRACTICE OF MEDICINE. 

have been reported by any of the above except lachesis and calabar. 
Veratrum viride has cured tetanic opisthotonus in cerebro-spinal 
meningitis. It is so antagonistic to strychnia that I am surprised it 
has not been used in tetanus by the dominant school. 

The true remedies for tetanus according to the law of similia 
should be all those drugs which contain strychnia — namely, angus- 
tura, ignatia, nux vomica, and arnica, but we have but few cases on 
record in our literature of cures by their use. Baehr says, " If there 
is any truth in the homeopathic law, nux vomica ought to cure 
tetanus." I said in my monograph on strychnia: "Until we can 
cure tetanus with strychnia we should be careful about boasting of 
the universality of the law of similia." 

As I observed many years ago, " a remedy that seems exquisitely 
homeopathic, somehow often fails to cure." I also suggested that 
traumatic tetanus in which strychnia would fail to cure might be 
different from the idiopathic. I did not then (in 1878) know of the 
bacillus of tetanus. 

But strychnia has cured tetanus, for Dr. Fell of New York, an 
old school physician, in 1847 reported seven cases treated with it, 
six of which it cured. One other case, reported by Dr. Kalloch, was 
cured by strychnia. They used doses of one-eighth to one-sixteenth 
grains every two hours, but observed aggravations after each dose. 
(Such doses would cause tetanus in a man.) 

These cases were all traumatic in their origin. No cases of 
idiopathic tetanus has yet been cured by strychnia. How can we 
account for these cures by large doses? Is it possible, as a noted 
Canadian physician teaches in his writings, that tetanus is partial 
paralysis, and that the spasms are contractions of muscles because 
the opposing ones are paralyzed ? There is abundance of proof that 
the secondary effect of strychnia is paralysis of the voluntary motor 
nerves of the whole body or a part of it, consequently of the muscu- 
lar tissues. According to my law of dose, if the secondary effects 
are present, material doses can be used. Still, I cannot account for 
the seven cures made by Dr. Fell with large doses, unless, as he 
gave it by the mouth, only a minute quantity was absorbed. I do 
not dare advise larger doses than the one-thousandth of a grain in 
tetanus. Our school has not yet tested it sufficiently to give any sat- 
isfactory evidence as to its power in this disease. 



SPECIFIC INFECTIOUS DISEASES. 83 

Caffeine is nearly as homeopathic to tetanus as strychnia, but no 
cases have been reported showing its curative effects. 

Passiflora incarnata has cured tetanus in horses and men, but it 
is antipathic, and must be given in massive doses. It has been 
found useful in tetanus neonatorum by Dr. Lindsay and Phares of 
Louisiana. In the tropics this disease carries off a large percentage 
of infants, chiefly blacks. If, as it is supposed, inattention to the 
umbilical cord and neglect to make it asceptic is the cause of this 
disease in those regions, passiflora alone will not cure. In the 
tetanus of horses it was found curative by Dr. Phares, who used the 
expressed juice of the roots, leaves, and flowers, mixed with water. 

In view of the discovery of the ptomaines of tetanus, it remains 
for some such brilliant observer as Dr. Burnett, of London, to pre- 
pare and use these ptomaines clinically in the treatment of tetanus, 
and the other variety of spasms caused by them. Tetanus is epi- 
demic in stables and in cavalry horses, but it is asserted that horses 
who have not been attacked are given immunity by inocculating 
them with the blood of those having tetanus. 

Hypericum perf . is reported to have cured : " After running pins 
in right foot ; pains run up the limb through the spine to neck and 
face ; muscles of neck and jaw become rigid, and also muscles of 
chest and abdomen." (~W. P. Hocking.) " Piercing wounds from 
pointed instruments should always be treated with hypericum to 
prevent any untoward symptoms." (Kaue.) 

Lachesis, according to Dr. I. Heber Smith, cured the following 
case : " One week after frost-bitten toe, which had been ulcerated, 
rigors, shooting pains in back, opisthotonus and trismus ; remission 
midnight till noon ; after midnight, profuse sweat and agitated sleep ; 
throat sensitive to contact ; swallowing fearful." I cannot find Dr. 
Smith's report of the case, which was doubtless written in more 
intelligible language. 

SYPHILIS. 

It is not intended to write extensively of this disease, as my expe- 
rience has not been sufficient to warrant me in so doing. My clien- 
tel has not been of the class in which the disease is common, yet I 
have some very decided opinions as to its treatment. 



84 THE PRACTICE OF MEDICINE. 

I wonder how many of our school in modern times have read 
Hahnemann's masterly monograph on Syphilis, which is to be found 
in his lesser writings, collected and arranged by Dr. Dudgeon ? It 
is worth while to read it even at this later day. I have lately re-read 
it, and compared it with that latest and most complete work on the 
subject by Dr. Keyes, and I find many remarkable resemblances in 
the two treatises. 

Hahnemann declares that there is but one specific remedy — and 
that is mercury. Keyes has words to the same effect. 

Hahnemann recommends his own preparation, the mercury sol- 
ubilis — a black oxide — because it is more soluble than any other, 
and can quicker saturate the whole system, thereby antidoting the 
virus of the malady and destroying the poison. He advises that it 
be used in small doses, sometimes as minute as one-tenth grain, 
given for a long time. 

Keyes advises principally the iodides of mercury for the same 
reason, and his treatment mainly consists in giving it in minute 
doses, one-sixtieth to one-tenth of a grain, continuing it for months 
at a time. 

Compare this simple treatment with that advised in the late text- 
books of our school, which recommend nearly one hundred medicines 
for syphilis and its various complications and manifestations! I 
have no hesitation in pronouncing this multiplication of remedies as 
illogical and absurd. Not more than six of all these one hundred 
medicines are really indicated in syphilis, for syphilis is not an aggre- 
gation of diseases, it is one disease due to one cause, and mercury 
in some form is the specific for it. All other remedies which have 
any decided and lasting effect on the disease are similar in their 
action, and can act only as aids to the one grand specific. These 
auxiliary remedies are iodide of potash, phytolacca (which contains 
a large amount of potash, and acts very nearly like kali biniod.), 
aurum, and its salts (close congeners of mercury), bichromate of 
potash (which resembles mercury), nitric acid (which is an analogue 
of mercury), and possibly sarsaparilla and stillingia. With these 
few remedies I have succeeded in relieving permanently every case 
of syphilis that I have been allowed to treat continuously. With 
this I shall leave the subject, adding that the only treatment I con- 
sider of value for congenital syphilis in children is the use of mer- 



SPECIFIC INFECTIOUS DISEASES. 85 

cury by inunction, the officinal unguentum hydrargyri, freely and per- 
sistently, until the disease is eradicated. Even in adults, the inunc- 
tion treatment sometimes gives the best results, especially in delicate 
women and broken-down men. I do not hesitate to recommend the 
physician to follow Keyes in nearly every particular 

In the treatment of secondary and tertiary syphilis, iodide of 
potash, combined or alternated with the bichloride of mercury, gives 
better results than any other method. 

I have carefully watched the treatment of those of our school who 
confine themselves to the high dilutions in this disease, and I am 
convinced that their asserted " cures " are unreal and illusory. 
Symptoms may disappear under their use, just as they disappear 
when no medicines at all are used, because it is the nature of the 
disease to have symptoms that change from one manifestion to 
another, continuously. 

DYSENTERY. 

Definition. — Under this general term are included several forms 
of intestinal flux, in which the principal symptoms are frequent stools, 
composed in part of blood and mucus, accompanied by colic (tor- 
mina) and tenesemus. Dysentery is classified as follows: (1) acute 
catarrhal dysentery ; (2) chronic catarrhal dysentery ; (3) tropical 
or amaebic dysentery ; (4) diphtheritic dysentery. In all these the 
lesions are generally confined to the large bowel from the ilio-cceeal 
valve to the anus. Not all the bowel is affected in every case. Some- 
times the inflammation is located in the transverse colon, and fre- 
quently confined to the rectum. In catarrhal dysentery the mucous 
membrane is injected, swollen, and covered with blood-stained mucus. 
The follicles are enlarged, and in children the picture is one of acute 
follicular enteritis. In protracted cases the follicles suppurate or 
are capped with an area of necrosed tissue. The old writers called 
this "canker of the bowels," and the phrase is used to this day 
among the common people. In severe cases the slough separates 
and the entire colon is covered with ulcers, developed from the dis- 
eased follicles, or from the intervening tissues. 

In the tropical, amaebic form, the lesions consist of ulcerations, 
preceeded by infiltration of the sub-mucous membranes. The ulcers 



86 THE PRACTICE OF MEDICINE. 

are of various shapes and sizes, with infiltrated undermined edges. 
The visible opening of the ulcer may be small, while the tissues 
beyond may be undermined to a great extent, forming sinuous tracts 
bridged over by apparently normal mucous membrane. The cause 
of this form of dysentery is supposed to be an organism called the 
amaebe coli. It is constantly present in the stools, and can com- 
municate the disease by infection, in the same manner that cholera 
and typhoid fever are communicated by being taken in food, drink- 
ing-water, or possibly by being inhaled. 

Diphtheritic dysentery is a form of colitis or entero-colitis. It is 
essentially a diphtheria of the bowels, and has the same anatomical 
appearance and lesions as are found in the throat when the disease 
attacks that locality. 

All bad cases of dysentery may cause abscesses in the liver, but 
tropical dysentery is more prone to cause this result than any other. 
Dysentery may be complicated with marsh malaria, giving it a peri- 
odic character. Woodbury in his army reports says that this was 
common in the army in the South. In Michigan I met with many 
cases, where the pain, fever, and bloody stools appeared with the 
regularity of an ague paroxysm. 

Symptoms. — There are some symptoms in common to all forms 
of dysentery. All are preceded by dyspeptic symptoms, pains in 
the abdomen, and some diarrhoea. Usually, in catarrhal dysentery, 
within thirty-six hours the characteristic features develop : the col- 
icky pain, griping, twisting, crampy, around the navel, extending 
into the back and hypogastrium, with frequent stools of mucus and 
blood, mixed with hard foecal balls, or f eculant matter. Afterwards 
the stools become gelatinous and bloody, sometimes almost pure 
blood. They vary in frequency from every two hours to every half- 
hour, and in severe cases the desire to evacuate is constant — the 
patient would like to remain on the vessel all the time. The strain- 
ing, or tenesemus, accompanies every stool, and is often constant 
and uncontrolable. There is usually some chilliness at the com- 
mencement, followed by fever, not very high, rising during the first 
days to 102° or 103°. The tongue is furred and moist at first, but 
as the disease progresses is red and glazed. Nausea and vomiting 
are sometimes present, and in rare cases persistent. The thirst is 
often excessive. At the end of the first week the mucus becomes 



SPECIFIC INFECTIOUS DISEASES. 87 

opaque, with less blood, and a gray or brown shreddy substance 
appears in the stools, which become less frequent. Sometimes the 
stools are skinny, membraneous, or made up of dark-green pulta- 
ceous matter and mucus. As the disease subsides fcecal matter 
again appears, and the stools become infrequent. I have observed 
that after the stools assume their normal form they are often coated 
with tough bloody mucus, and are attended by pain in the hypogas- 
trium, extending to the back and rectum. In the tropical or amae- 
bic dysentery, which is probably the "camp dysentery" of soldiers, 
the symptoms are somewhat different. There is a mixture of diar- 
rhoea and dysentery, marked by remissions and aggravations, emaci- 
ation, without much fever. The stools may contain blood and mucus, 
but are generally watery ; from six to twelve yellowish-gray liquid 
stools are passed daily for weeks. Kecovery is tedious, owing to 
muscular weakness and anaemia, with recurring relapses. The mor- 
tality is much higher than in catarrhal dysentery. This form is epi- 
demic, and is doubtless infectious : the amaebe are carried by the 
water used by the soldiers in camps, or contaminated wells and 
streams. I have seen two epidemics of this variety in Michigan 
villages, originating from returned soldiers. 

The symptoms of diphtheritic dysentery are very severe at the 
onset, when the disease is primary. The patient is attacked sud- 
denly with high fever, great prostration, violent pain in the abdo- 
men, and frequent discharges. Delirium is common, and the disease 
is often mistaken for typhoid. The abdomen is tender and distended 
(in catarrhal dysentery it is usually hard but flat). Blood and 
mucus may appear in the stools, but are not constant, nor is tenese- 
mus always present. If the disease is secondary from other dis- 
eases, as pneumonia or diphtherial angina, the symptoms are masked 
and difficult of diagnosis. This disease in both forms is very fatal, 
the patient dying from asthenia, or a condition similar to blood- 
poisoning. 

Chronic dysentery resembles chronic diarrhoea ; the pathological 
conditions in both are similar. The former, however, is more pros- 
trating and more fatal. The anaemia is more profound, and the 
emaciation extreme. The ghastly appearance of the face is similar 
to that in gastric cancer. The stools are a mixture of mucus, blood, 
shreddy and necrotic tissue ; or are thin, frothy, and contain parti- 



88 THE PRACTICE OF MEDICINE. 

cles of food. I have seen many cases in which obstinate constipa- 
tion lasting a week or more would alternate with dysenteric stools 
containing small hard scybala coated with bloody mucus. Certain 
articles of food may pass undigested, while other articles seem to 
digest well. Food which one patient can digest others cannot. 
Sometimes the stools are almost destitute of bile. Pus often appears 
in the stools in patients of scrofulous or tuberculous habit. Flatu- 
lence is a distressing symptom, causing painful distension and con- 
siderable tenderness along the course of the colon. The tongue is 
not often furred, but is generally beefy, or smooth and glazed. 

Treatment. — Simple catarrhal dysentery is, when mild and not 
epidemic, a self-limited disease. Under purely dietetic or expec- 
tant treatment, it will run its course in eight or nine days. The 
former old-school treatment of such cases, with opium, calomel, and 
rhubarb in large doses, generally caused it to be protracted beyond 
its normal limits. The treatment by our school, with non-medicinal 
globules conjoined with strict diet, was so much more successful that 
it redounded greatly to the credit of homeopathy. In accordance 
with the law of similia the medicines indicated in dysentery are 
those that will produce in healthy persons all the phenomena of the 
disease. Of all drugs in the materia medica the mercurials most 
invariably cause dysenteric phenomena, not only the subjective symp- 
toms, but the pathological state of the colon and other portions of 
the intestinal tube. 

It would be useless and unnecessary for me to give all the symp- 
toms that indicate each mercurial preparation, for the physician is 
supposed to know them, or can readily find them in his materia 
medica. I shall therefore only give my experience as to the prep- 
arations I consider most potent, and the method of administration 
which I prefer. 

During the first ten years of my practice I used mercurius solu- 
bilis-Hahnemanni in the 3x trituration. Not meeting with the suc- 
cess I thought it ought to bring, I tried the sixth, twelfth, and the 
thirtieth. From these latter attenuations I can truly assert I never 
observed any decided results. Afterwards I commenced to use mer- 
curius vivus 2x and 3x, and I believe it a more potent curative 
preparation than the former. Twenty-five years ago, in an epidemic 
of catarrhal dysentery of unusual severity, I tested both the above 



SPECIFIC INFECTIOUS DISEASES. 89 

preparations side by side with mercurius dulcis, and was very favor- 
ably impressed with its superiority over others, and since that time 
I have rarely used any other mercurial in dysentery. In the begin- 
ning of the attack I give aconite or gelsemium in alternation with 
mercury, so long as the high temperature lasts ; then continue the 
mercurius alone until the subsidence of the disease. 

Mercurius corrosivus corresponds to severer forms of dysentery, 
and when it is epidemic, or when, owing to malarial influences, it 
has a dynamic character. In poisonous doses it is more sure to 
cause all the severer pathological lesions, even to gangrene, than 
any other preparation of mercury. It is indicated when all the 
usual symptoms are intensified, and the strength of the patient is 
fast failing. The old school gives, as recommended by Ringer, the 
one-hundredth of a grain every two hours ; but I know from per- 
sonal observations that such doses are hazardous if continued more 
than a day. I have seen severe aggravations follow the use of such 
doses. Some persons are so susceptible to the corrosive mercury 
that a single dose of one-hundredth of a grain will salivate and purge, 
especially if the person has previously been salivated by mercury. 
When indicated by the severity of the symptoms, I have seen excel- 
lent results from the fourth and sixth triturations, and in very sus- 
ceptible patients from the twelfth. 

Podophyllum ranks next to mercury in the treatment of catarrhal 
dysentery. The four chief indications which I follow in its selec- 
tion are : the glairy bloody stools ; the violent tenesemus ; the pain 
in the back ; and griping, with nausea, before each stool. The ten- 
esemus leads to a prolapsus recti, which indicates this drug before 
all others. Podophyllum can hardly cause ulceration, necrosis, or 
sloughing of the mucosa, but its effects may reach so far as to cause 
follicular inflammation. The dose ranges from the 2x dilution of 
the tincture, or the 6x trituration of podophyllin, for children ; and 
one to five drops of the tincture ; or one grain of the 2x trituration 
of podophyllin for adults — the dose to be repeated every two or 
four hours. 

Khubarb is an admirable remedy at the outset of the disease, as 
well as during its decline, when the following symptoms occur : The 
griping is severe, and the stools are f cecal, but soft and papescent — 
of a strong sour odor, and but little mucus. In all such cases the 



90 THE PRACTICE OF MEDICINE. 

lx trituration or dilution of the tincture, in one-grain or one-drop 
doses every two hours, soon arrests the disease. It is of no value for 
any other form. 

Magnesia sulph lx is useful for the same symptoms of the stools, 
but there is no tenesemus and but little griping, though the stools 
are profuse and frequent. It is also useful when the disease begins 
with copious watery stools, with rumbling and distension of the abdo- 
men, and when the disease is caused by a sudden change of temper- 
ature ; this copious watery diarrhoea commonly precedes the mucus 
and bloody discharges. I ought to mention that while all recent old- 
school authorities condemn the use of cathartics in dysentery, they 
advise the use of laxative doses of this drug (epsom salts) in the 
beginning, if the patient has been constipated. There is no salt 
which irritates the bowels so little as this, while the large watery 
stools wash away the large or small hard concretions of f ceces, which, 
if allowed to remain, cause great irritation to the inflamed mucosa, 
and prolong the disease. One teaspoonful of a saturated solution of 
this salt, repeated every half -hour, will show its effects after three 
or four doses. In this connection I will observe that I am sure that 
the importance of cleaning out the bowel of all foecal matter in the 
beginning of an attack of dysentery is not fully appreciated by our 
school. If the mucus and bloody discharge with tenesemus com- 
mence suddenly, not preceded by any looseness, but by constipation, 
no time should be lost ; the colon should be washed out by an enema, 
or a dose of epsom salts, or carlsbad, or castor oil ; then we are sure 
no foreign substance, scybala, or concretion of undigested food, 
remains to ferment or irritate the colon. 

Colocynth and dioscorea are two remedies indicated chiefly by 
the element of pain, — colocynth when the pain is around the umbil- 
icus and extends to the groins, legs, and sides of the abdomen, and 
is relieved by pressure ; dioscorea when the pain is twisting, tear- 
ing, spasmodic, and radiates to the chest and sometimes to the hands 
and feet. Both medicines have painful flatulence. Both have rum- 
bling and barborygmus, but neither have marked tenesemus. The 
stools of colocynth are feculent, mucus, and sour ; those of dio- 
scorea, foecal, lumpy, albuminos, with burning in the rectum. Dose : 
lx or 3x of colocynth ; mother tincture or lx of dioscorea. The best 
and most prompt effects from the latter are gained when it is given 



SPECIFIC INFECTIOUS DISEASES. 91 

in a hot infusion made by adding one drachm of the powdered root 
to four ounces of boiling water, giving a teaspoonful every fifteen 
minutes. 

Aloes is an invaluable medicine in some cases of dysentery, but 
it is not indicated in general. The symptoms are few and sharply 
defined : when the abdomen seems to the patient to be greatly dis- 
tended, but is not ; when it is tender on pressure ; when the descend- 
ing colon and rectum are chiefly affected ; the stools are scanty, 
watery, bloody, jelly-like, or composed of a little foul-smelling mucus, 
with painful tenesemus, which forces the hemorrhoidal vessels out ; 
then this drug in doses of a few grains or drops of the 2x will 
promptly modify the severity of the attack. 

Ipecac is useful in some cases of sporadic dysentery, but I never 
found it specific in the epidemic form, such as we see in the temper- 
ate zone. When the nausea and vomiting are coincident with the 
stools and tenesemus and the stools are dark-green, or like frothy 
molasses, then the 2x or 3x trituration of the powdered root acts 
magically. We can hardly understand the great reputation that 
ipecac has gained in the treatment of tropical epidemic dysentery. 
If we can trust the annals of Anglo-Indian physicians, it comes very 
near being a specific ; but their method of giving it throws a doubt 
on its specific value. They give a preliminary full dose of opium, 
then twenty to sixty grains of the powdered root. If rejected, the 
dose is repeated. They assert its use in this manner cuts short the 
disease. It certainly does not act thus favorably in North America, 
nor, according to army surgeons during the late war, in the epidemics 
which prevailed in the camps. The late Dr. Whelan found it val- 
ueless in the epidemics of dysentery occurring in Camp Douglas 
(Chicago) during the war ; but he did find that nux vomica and 
strychnia would cure nearly every case. 

Nux vomica acts in dysentery through the spinal system. It will 
cause, not a true entero-colitis, but an irritation of the musculo- 
nervous structure of the bowels, simulating it. When a dysentery 
is the result of torpor of the intestines with constipation, which 
results in morbid irritability of the whole intestinal tract, then is 
nux vomica specific. The stools are small, composed of mucus mixed 
with hard foecal matter, and followed by relief from pain and tenes- 
emus ; or when the anus is non-retentive from paralysis of the spine- 



92 THE PRACTICE OF MEDICINE. 

ter, nux or strychnia are useful. I prefer the 2x or 3x of nux and 
the 3x of strychnia. 

Nitric acid has many symptoms in common with mere, corr., for 
it is a near analogue of that drug. It is capable of causing the same 
pathological lesions in the intestines. I prefer it to mercury when 
the stools are very scanty, and the tongue very red, but not dry or 
glazed. Dose : a few drops of the dilute acid, enough to slightly 
aciduate water, given in frequent teaspoonful doses. It has been 
observed that so soon as bile appears in the stools (the green slime 
in dysentery is not bile, but due to a microbe,) amelioration soon 
follows. This is probably due to the fact that bile is anodyne, and 
antiseptic in its action. The old school seek to establish the flow of 
bile with calomel or podophyllin, but unless very small doses are 
given they are liable to increase the intestinal irritation. There are, 
however, two medicines which increase or restore the normal flow of 
bile, without irritating the bowels — these are euonymin and sodium 
salicylate. I have frequently given euonymin 2x trituration, a tab- 
let or one grain every two hours, with decided benefit ; and I have 
given the sodium salicylate, a one-grain tablet of the crude, every 
two hours, with as good results, especially when the evacuations are 
offensive. I should expect good effects from this medicine in amaebic 
dysentery. Probably salol, which has a similar action on the liver, 
and on amsebe, would give better results, as it dissolves only in the 
intestinal secretions. 

Cantharis presents a good picture of dysentery complicated with 
cystitis, arnica, colchicum, gambogia, croton tig. hamamelis, arg. nit. 
baptisia, magnesia phos., and others are occasionally useful. 

Arsenicum is sometimes indicated in malarial dysentery, when 
its symptoms are prominent, but I have never found it useful in 
ordinary cases. As an intercurrent remedy for great agitation, 
anxiety and prostration, it acts well. When the malarial influence 
is decided enough to cause diurnal paroxysm of dysentery with 
apyrexia, quinine in doses of one grain every hour, or five grains an 
hour or two before the paroxysms, will arrest them. Cedron has had 
a similar antiper iodic effect in such cases. 

Capsella bursa pastoris (shepherd's purse) has been of great value 
when the amount of blood in the stools amounts to a real hemor- 
rhage. Erigeron, millefoil, turpentine, and hamamelis are equally 



SPECIFIC IXFECTIOUS DISEASES. 93 

useful in such cases. Erigeron and turpentine are indicated when 
the tongue is dry, smooth, and glazed. This symptom is also found 
in aurum mur., which also causes as good a pathological picture of 
gastro-enteritis as nitric acid. I would advise a trial of gold in 
obstinate, chronic cases. 

Certain medicines have been enumerated among the remedies for 
dysentery, which have no sort of relationship to that disease, and 
their use is a waste of time. Because some of their symptoms are 
similar to those of dysentery, is no indication that they are of value. 
Bryonia, chamomilla, apis, china, carbo. veg. conium, dulcamara, 
Pulsatilla, etc.. are never useful to combat the pathological state or 
the serious symptoms. 

I must protest against the practice of some of our school of 
changing the medicine selected, because of some change in the color 
of the stools, their odor, or appearance. The stools in dysentery 
change in appearance, etc., every hour or two, and to follow these 
changes with new medicines is like chasing a will-o'-the-wisp. I have 
seen our symptom-hunting " cranks " change medicines in a case a 
dozen times a day, to meet the varying colors or smell of the stools, 
when all the time one medicine alone was indicated and should have 
been continued for days. 

The late authorities of the old school contend that the topical 
treatment of dysentery is the most rational. They recognize, how- 
ever, that in acute cases it is almost impossible for the patient to 
retain large injections. If given at all, two or more quarts of hot 
water, medicated or not, should be used. Hot water thrown into the 
colon is very agreeable and soothing. Few patients, however, can 
bear the introduction of the colon tube, or rectal nozzle, unless a 
solution or suppository of cocaine is first used in the rectum. 

In one epidemic in 1857 I became desperate on account of the 
unsuccessful use of our best indicated medicines. If called to a 
recent case I began by injecting a quart of hot water, containing a 
teaspoonful of McMunn's elixir of opium, into the colon, the patient 
lying on the back with the hips elevated. In many cases, if recent, 
one injection was all that was necessary to arrest the disease, and in 
nearly all cases it was beneficial. Laudanum or opium was not use- 
ful, and did not act favorably. As a general rule opium does more 
harm than good in dvsentery or diarrhoea. If relief from intense 



94 THE PRACTICE OF MEDICINE. 

pain and tenesmus is necessary, codeine is much to be preferred, as 
it does not constipate or cause gastric irritation. One-fourth of a 
grain by mouth or hyperdermatically, rarely has to be repeated more 
than once. If codeine cannot be obtained, the usual dose of mor- 
phine with atropine will give relief, and will not interfere with the 
action of the indicated specific drug. 

The use of astringents, — alum, zinc, lead, copper, tannin, or 
brandy, ginger, etc., — is reprehensible, and of no value. In chronic 
dysentery, injections of nitrate of silver have been found curative, 
if we can trust the reports of Drs. Hare, McKenzie, and H. C. Wood. 
They recommend twenty grains to the pint of water, and the amount 
to be injected not less than three to six pints, and allow it to run 
into the colon through a fountain syringe. "It is at times intensely 
painful and rejected at once." Without denying its curative action 
in chronic cases, I believe we have less dangerous remedies at our 
command, but I should not hesitate to use it in desperate cases. 

Osier says quinine has been used successfully in the Johns Hop- 
kins Hospital in amoebic dysentery. The solution used varied from 
1 to 1,000 to 1 to 2,500. He says the amoebaee are rapidly destroyed 
by it. Probably they are, but quinine is not at all indicated for 
the intestinal inflammation. I have known a quart of peppermint 
infusion, or extract hamamelis, one part to three parts of water, 
used with apparent success. In one epidemic I used with good 
effect an infusion of eucalyptus leaves, in another a distilled extract 
of eucalyptus. An external application of dilute arnica tincture, or 
turpentine, will often relieve the great tenderness of the abdomen ; 
they may be incorporated in a poultice or on cotton or wood-wool. 

Diphtheritic dysentery requires the same medicines as for diph- 
theria in other locations. The most prominent are mere, cyan., kali 
bichromatum, phytolacca, and kali permanganate. The diet should 
be restricted in acute cases to milk, which should be Pasteurized or 
peptonized unless fresh from the cow. Next to milk come whey, 
broths (particularly lamb or mutton broths), gruels made of rice or 
barley flour (never of oatmeal). When starchy food is given it is 
advisable to give with each meal a small quantity of diastase. When 
the disease is subsiding, Libby's meat-juice may be given, and the 
patient allowed to chew roast beef, or dried beef, swallowing only 
the juices. The best beverage is white of egg beaten up in water, 



SPECIFIC INFECTIOUS DISEASES. 95 

two or three being used for each gobletful, with the addition of a 
little sugar. In long-lasting or chronic cases a stronger diet can be 
used, but never a large quantity at once. There is an unfounded 
objection to the sub-acid juice of fruits. I have seen the best results 
from the juice of grapes, peaches, and the grape-fruit — a large spe- 
cies of the orange family. In some cases peaches, if ripe and not 
too acid, can be eaten with benefit. Bacon is always relished, and 
if the fat only is swallowed never disagrees with the patient. One 
of the greatest obstacles to the cure of dysentery in children is their 
restlessness. If kept quiet, and not allowed to sit up while at stool r 
a greater number would recover. 



CHOLERA ASIATICA. 

The history and etiology of cholera, if fully given, would fill a 
volume. All that is required in a work of the scope of this book is 
a brief and clear account of the pathology, symptoms, and treatment 
of the disease. I find no writer gives such a clear description of 
cholera, in as few words, as Osier, in his "Practice of Medicine," 
and as he is an exponent of the most recent discoveries in pathology, 
his statements may be relied upon. I therefore quote his etiology 
and pathology, with a few observations and additions of my own. 

"History. — Cholera has been epidemic in India for a remote 
period, but only within the present century has it made inroads into 
Europe and America. An extensive epidemic occurred in 1832, in 
which year it was brought in immigrant ships from Great Britain 
to Quebec. It traveled along the lines of traffic up the Great Lakes, 
and finally reached as far west as the military posts of the Upper 
Mississippi. In the same year it entered the United States by way 
of New York. There were recurrences of the disease in 1835-1836. 
In 1848 it entered the country through New Orleans, and spread 
widely up the Mississippi valley and across the continent to Califor- 
nia. In 1849 it again appeared. In 1854 it was introduced by 
immigrant ships into New York, and prevailed widely throughout 
the country. In 1866 and in 1867 there were less serious epidem- 
ics. In 1873 it again appeared in the United States, but did not 
prevail widely. In 1884 there was an outbreak in Europe. Although 



96 THE PRACTICE OF MEDICINE. 

occasional cases have been brought by ship to the quarantine stations 
in this country, the disease has not gained a foothold here since 
1873. 

"Etiology. — In 1884 Koch announced the discovery of the spe- 
cific organism in this disease. Subsequent observations have con- 
firmed his statement that the comma bacillus, as it is termed, occurs 
constantly in the true cholera and in no other disease. It has the 
form of a slightly bent rod, which is thicker but not more than 
half the length of the tubercle bacillus, and sometimes occurs in an 
S form. It is not a true bacillus, but really a spirochete. The 
organism grows upon a great variety of media, and displays distinct- 
ive and characteristic appearances. The bacilli are found in the 
intestines, in the stools from the earliest period of the disease, and 
very abundantly in the characteristic rice-water evacuations, in which 
they may be seen as an almost pure culture. They very rarely occur 
in the vomit post-mortem ; they are found in enormous numbers in 
the intestines. In acutely fatal cases they do not seem to invade 
the intestinal wall, but in cases with a more protracted course they 
are found in the follicles, and even in the deeper tissues. They 
require an alkaline medium for their growth and development. 

"Modes of Infection. — (1) Contagion. — It appears probable that 
cholera is not highly contagious in the same sense as small-pox and 
scarlet fever, but in this respect is very similar to typhoid fever. 
Physicians, nurses, and others in close contact with the patients are 
often not affected. On the other hand, such persons as washerwomen, 
who are brought into very close contact with the cholera stools and 
the linen of cholera patients, are particularly prone to the disease. 

" (2) Infection. — The leading authorities now agree that the dis- 
ease is propagated chiefly by the contamination of water used for 
drinking, washing, and cooking. It is quite possible that articles of 
food may be contaminated, particularly vegetables, such as lettuces, 
cresses, and others, which have been washed in infected water ; also 
on the skin of fruit sold at fruit stands, and kept at night in filthy 
rooms where cholera has been, but this is probably a minor danger 
in comparison with impure drinking-water. The bacilli, under suit- 
able circumstances — that is, when much impurity is present — may 
develop to some extent in the water. Koch, as is well known, found 
the bacilli in a tank in India from which the inhabitants were sup- 



SPECIFIC INFECTIOUS DISEASES. 97 

plied with water for drinking and washing. Strongly in favor of this 
view is the fact that the virulence of an epidemic in any region is 
generally in direct proportion to the imperfection of the water sup- 
ply. On the other hand, with improvements and perfection in the 
waterworks of a place, the epidemics are reduced in intensity, and 
the place may even obtain immunity against the disease. Not only 
in India has the demonstration of the connection between drinking- 
water and cholera infection been amply furnished, but in England 
there have been many valuable illustrations. One of the most notable 
of these was the celebrated Broad street pump, in London, which, in 
1854, was connected with a severe epidemic. Milk also may pos- 
sibly in some instances convey the poison. The germs may be con- 
veyed through the atmosphere. This has been denied, but it is diffi- 
cult to account for genuine isolated cases on any other theory. 

" Symptoms. — A period of incubation of uncertain length, prob- 
ably not more than from two to five days, precedes the development 
of the symptoms. Three stages may be recognized in the attack : 
the preliminary diarrhoea, the collapse stage, and the period of re- 
action. 

" (1) Preliminary Diarrhoea. — This may set in abruptly without 
any previous indications. More commonly there are, for one or two 
days, colicky pains in the abdomen, with looseness of the bowels, 
perhaps vomiting, with headache and depression of spirits. There 
may be no fever. 

" (2) Collapse Stage. — The diarrhoea increases, or, without any 
of the preliminary symptoms, sets in with the greatest intensity ; and 
profuse liquid evacuations succeed each other rapidly. There are 
in some instances griping pains and tenesmus. More commonly 
there is a sense of exhaustion and collapse. The thirst becomes 
extreme ; the tongue is white : cramps of great severity occur in the 
legs and feet. "Within a few hours vomiting sets in and becomes 
incessant. The patient rapidly sinks into a condition of collapse, 
the features are shrunken, the skin of an ashy gray hue, the eye- 
balls sink in the sockets, the nose is pinched, the cheeks are hollow, 
the voice becomes husky, the extremities are cyanotic, and the skin 
is shrivelled, wrinkled, and covered with a clammy perspiration. 
The temperature sinks. In the axilla, or in the mouth, it may be 
from 5° to 10° below normal, but in the rectum and in the internal 



98 THE PRACTICE OF MEDICINE. 

parts it may be 103° or 104°. The pulse becomes extremely feeble 
and flickering, and the patient gradually passes into a condition of 
coma, though consciousness is often retained until near the end. 

" The faeces are at first yellowish in color, from the bile pigment, 
but soon they become grayish white, and look like turbid whey 
or rice-water — whence the term 'rice-water stools.' There are 
found in it numerous small flakes of mucus and granular matter, and 
at times blood. The reaction is usually alkaline. The fluid contains 
albumen, and the chief mineral ingredient is chloride of sodium. 
Microscopically, mucus and epithelial cells and innumerable bacteria 
are seen, the majority of the latter being the comma bacilli. 

" The condition of the patient is largely the result of the concen- 
tration of the blood consequent upon the loss of serum in the stools. 
There is almost complete arrest of secretion, particularly of the 
saliva and the urine ; on the other hand, the sweat glands increase 
in activity, and in nursing women it has been stated that the lacteal 
flow is unaffected. This stage may not last more than two or three 
hours, but more commonly lasts from twelve to twenty-four. There 
are instances in which the patient dies before purging begins — the 
so-called cholera sicca. This form often occurs after a fright, or 
shock from fear. 

" (3) Reaction Stage. — When the patient survives the collapse 
the cyanosis gradually disappears, the warmth returns to the skin, 
which may have for a time a mottled color, or present a definite 
erythematous rash. The heart's action becomes stronger, the urine 
increases in quantity, the irritability of the stomach disappears, the 
stools are at longer intervals, and there is no abdominal pain. In 
the reaction the temperature may not rise above normal. Not infre- 
quently this favorable reaction is interrupted by a recurrence of 
severe diarrhoea, and the patient is carried off in a relapse. Other 
cases pass into the condition of what has been called cholera-typhoid, 
a state in which the patient is delirious, the pulse rapid and feeble, 
and the tongue dry. Death finally occurs with coma. These symp- 
toms have been attributed to uraemia." 

Diagnosis. — The only affection with which Asiatic cholera could 
be confounded is the cholera nostras (morbus) — a severe choleraic 
diarrhoea which occurs during the summer months in temperate cli- 
mates. The clinical picture of the two affections is identical. The 



SPECIFIC INFECTIOUS DISEASES. 99 

extreme collapse, vomiting, and rice-water stools, the cramps, the cyan- 
osed appearance, are all seen in the worst forms of cholera nostras, 
or cholera infantum. In enfeebled persons death may occur within 
twelve hours. It is, of course, extremely important in some instances 
to be able to diagnose between the two affections. " This can only be 
done by one thoroughly versed in bacteriological methods, and con- 
versant with the diversified flora of the intestines. The comma bac- 
illus is present in the dejections of a great majority of the cases, and 
can be seen on cover-glass preparations. Though the eye of the 
expert may be able to differentiate between the bacillus of true chol- 
era and that which occurs in cholera nostras, cultures should be made, 
from which alone positive results can be obtained." (Olser.) Pois- 
oning by arsenic, copper, veratrum album, phytolacca, podophyllum, 
castor oil beans, euphorbia cor. iatropha, and mere, corr., all present 
symptoms almost identical with those of cholera. Fright and fear 
will in some sensitive persons cause similar symptoms. Aconite 
causes a condition resembling cholera sicca. 

Prevention. — The first step to be taken by the government of 
any city or state, when cholera is present in a foreign country, is to 
establish the most rigid quarantine at every avenue of entrance, by 
ships, railroads, or any other means of travel. On several occasions 
cholera has been brought to various parts of America, but has been 
checked by quarantine. The general government of the United 
States should exercise chief supervision over quarantine during the 
prevalence of epidemics in foreign countries. For this reason I am 
in favor of a national board of health. 

The next method of prevention is to perfect the sanitary condition 
of towns and cities. Sewers, cesspools, gutters, pools of stagnant 
water, out-of-door water-closets, may all be sources of infection and 
culture-mediums for the bacillus. When the sewers of a great city 
empty into a lake or river, the water for many miles becomes in- 
fected, and often goes back to the city through the intakes of the 
cribs, and into the dwellings of its inhabitants. During the preva- 
lence of any epidemic (especially of cholera and typhoid), all the 
water for drinking, or used for washing cooking utensils, should be 
boiled. Mere filtering, even with a Pasteur filter, is not sufficient, 
for even if the bacillus is filtered out, the toxic excretions from them 
pass through, and can be destroyed only by boiling for at least five 



100 THE PRACTICE OF MEDICINE. 

minutes. Water-closets and cesspools, filthy gutters, and all stand- 
ing pools should be cleaned at night, and thoroughly flushed with 
a solution of sulphuric acid or sulphate of copper. One pound of 
either will make several barrels of disinfecting fluid. 

All persons should pursue their usual vocations, to occupy the 
mind and prevent it from dwelling on the disease. Fright and fear 
are great predisponents. I know of many instances in my own prac- 
tice in which a morbid fear of the cholera was the exciting cause of 
a fatal attack. Indeed, such were their isolated surroundings, and 
the care they exercised, that I doubt if bacilli had anything to do 
with the attack. Morbidly sensitive persons should not read about 
cholera, nor should the disease be' discussed in their presence. The 
habitual diet should not be changed, except to eliminate such articles 
of food as unripe or overripe fruits and vegetables, and stale or 
" high " meats. All ripe clean fruits and vegetables, especially if 
cooked, are allowable. In persons habitually accustomed to the use 
of wines and liquors, their moderate use should be kept up. The 
acid wines are best, also acid fruits, for the comma baccillus cannot 
live long in an acid medium. A low diet of unsubstantial food is 
dangerous. 

In the sick-room the stools and linen of the patients should be 
thoroughly disinfected by the use of sulphuric acid, Piatt's chlorides, 
or carbolic acid, or destroyed by fire. 

Medicinal Prophylaxis. — It was hoped that a protective virus 
prepared according to the rules of Pasteur would be found ; but 
inoculations with such virus have not been satisfactory. There has 
been no proof of their positive preventive power. 

It has been observed that the workmen in copper manufactures 
and copper smelters, and even those who live in their immediate 
neighborhood, generally escaped the cholera. This has led to the 
use of copper internally and externally as a preventive. Cuprum 
metallicum 3d and 6th, as advised by Hahnemann, have been given 
during epidemics, with the apparent result of preventing the disease ; 
small bands or discs of copper have been worn around the waist, or 
on the epigastrium, with apparently protective effects. 

I prefer the arseniate or arsenite of copper, for I believe arsenic 
has also protective powers. The arsenite of copper is very soluble, 
and is readily absorbed into the circulation. Tablets, or pills, con- 



SPECIFIC INFECTIOUS DISEASES. 101 

taining the one-hundredth, one-five-hundredth, and one-thousandth 
are now used. Either preparation can be used, the dose varying 
with the age and susceptibility of the individual. A dose morning, 
noon, and night, after meals, may prove a preventive. Veratrum 
album has been recommended as a preventive, but I doubt its value. 
It is best indicated when the attack is present, or during the initial 
diarrhoea. 

As the comma bacillus must have an alkaline medium for its 
development, it has been suggested that in order to protect against 
it, the intestinal and gastric secretions should be kept in an acid con- 
dition. Sulphuric acid has been used for this purpose. It is pre- 
pared as follows : A few drops, ten or fifteen, of the dilute acid are 
added to a glass of water, with or without a small quantity of sugar, 
and flavored with a slice of lemon if desired. It is about the one- 
two-thousandth solution. This makes a mild acid drink, and several 
glasses daily can be used without injurious results. On the con- 
trary, it is a tonic ; it improves digestion and will prevent and cure 
most forms of atonic diarrhoea. This acid has been employed with 
great advantage in epidemics of cholera by Dr. Curtis in the Phila- 
delphia Almshouse, insane department. A very serious epidemic 
ceased in twelve hours after the inmates were all put upon the free 
use of sulphuric-acid lemonade. The only new case after this was 
that of a man who refused to use the prophylactic. Two days after 
the use of sulphuric acid was stopped two new cases occurred, and 
the epidemic was again arrested by the use of the sulphuric acid. 
In the surgical wards the acid was used from the beginning of the 
epidemic, and in these wards, although in no way isolated, the dis- 
ease failed to make an appearance. In view of this statement of 
facts it should be used freely and early. In such small quantity, 
the acid is not absorbed into the blood, and if it is it will not dis- 
turb its normal alkalinity, being immediately neutralized. 

Phosphoric acid is nearly as valuable, prepared in the same man- 
ner. The " acid phosphates " are not useful, and may be injurious, 
for they separate in the stomach, leaving an alkaline or neutral solu- 
tion. Lime juice, lemon juice, or vinegar in water may all be useful. 

In Dr. Moore's " Keport on the Cholera Epidemic of 1849 " I 
find the following : " Dr. Tommaso Cigliano gives a very interesting 
account of the cholera in Xaples in 1884. In this account the high 



102 THE PRACTICE OF MEDICINE. 

reputation of camphor in cholera is fully sustained, and much addi- 
tional testimony is given in reference to its power as a preventive 
of the disease ; this is a matter of the most vital moment, and sup- 
plies a missing link in reference to what is known as prophylactic 
treatment of cholera. Hitherto cuprum only was ascertained to have 
such properties, but camphor being a much more easily managed 
medicine the gain of such knowledge is no small advantage. On 
this head Dr. Cigliano states that he, in common with his colleagues, 
Drs. Rubini, Mucci, and Orioli, administered camphor to their pri- 
vate patients, families, and households, amounting in all to about 
2,000 persons, during the period the disease was raging in Naples, 
as a protective measure, and not one of those people took the dis- 
ease. They gave drop doses thrice a day ; then at their free dis- 
pensary they gave camphor to the public generally. They calculate 
that about 50,000 persons in all in the city took camphor. They 
confidently affirm that not one of said persons died of cholera, though 
they nursed, in some instances, cholera patients, and lived in houses 
where patients died of the disease ; and thus, with very few excep- 
tions, all the above escaped an attack. [A disc, or tablet, con- 
tains two drops of camphor. One of these four times a day should 
be taken when the disease is prevailing.] Thus we have accum- 
ulated testimony to the efficacy of this potent remedy as a prevent- 
ive of the disease, as well as to its curative power. Then, in refer- 
ence to the external applications of camphor, Dr. Cigliano states 
that when camphor could not be given internally, as in the case of 
children, it answered equally well if rubbed in on the temples, arm- 
pits, and over the stomach. This testimony is very assuring, as in 
some cases it cannot be borne on the stomach in quantities sufficient 
to produce the necessary reaction — hence the importance of this 
observation. In addition to the above he recommends it in the form 
of enema with warm oil, if needful. His dose internally was five 
drops frequently repeated. The mortality under regular treatment 
in this epidemic was very high. From August 2 to October 10 there 
were attacked 11,384 persons ; of these, 6,042 died. 

" Though the homeopathic doctors pressed upon the authorities 
the immense advantages of adopting homeopathic treatment, the 
Minister of the Interior declined on technical grounds, and Death 
may be truly said to have had his undisputed sway, if, indeed, he 



SPECIFIC INFECTIOUS DISEASES. 103 

had not in many instances been helped by haphazard Allopathy. 
The veteran Rubini, now eighty-four years of age, but still full of 
youthful vivacity, actually offered to take charge of half of the 
cholera hospitals, which, with his colleagues, he could have done, and 
I doubt not have saved many lives ; but ignorance, prejudice, and 
officialism combined to prevent it." 

The acid preventive treatment can be given together with the 
cuprum, or camphor. The selection of the two latter medicines will 
depend on the genius or characteristic symptoms of the prevailing 
epidemic. Camphor is not such an antidote to other drugs as has 
been taught by some authorities, for many eminent practitioners have 
alternated it with other remedies in the treatment of cholera, and 
have not observed any antidotal action from it. 

Treatment. — In the initial stage, usually termed cholerine, a 
diarrhoea which sometimes precedes for several days the violent 
symptoms, the diet should be restricted to plain nutritious food and 
drinks. If the acids do not prevent or arrest it, select the remedy 
carefully according to its characteristic symptoms. The experience 
of our school has been that camphor is here the chief remedy. I 
have seen cases, however, which required mere. cor. iris, podophyl- 
lum, and arsenicum. If you are using the arsenite of copper as a 
preventive, do not stop its administration, but give smaller doses. 
If the patient is taking the 2x, give the 3x. The use of opium, and 
all preparations containing that drug, is certainly injurious ; so are 
ginger, capsicum, and other similar aromatic and astringent drugs. 
When the pain in the bowels is violent, and resists fomentations and 
the selected remedy, a hypodermatic injection of codeine phos., one- 
half a grain is admissible. 

The onset of cholera is often sudden, and not preceded by any 
looseness of the bowels. The patient is stricken with violent vom- 
iting and purging and immediate collapse. In such cases he should 
be put into a warm bed between flannel sheets, and not allowed to 
go to the water-closet, but made to use the bed-pan. Camphor, a 
concentrated tincture ("Rubini's camphor"), should be given in 
doses of five drops every ten minutes, until the symptoms are miti- 
gated. It is the universal testimony of the homeopathic and of a 
portion of the regular school, that camphor is a powerful remedial 
agent in these sudden and violent cases. My experience with cam- 



104 THE PRACTICE OF MEDICINE. 

phor, given in pure chloroform, for cholera morbus and cholera 
infantum, impels me to recommend it in true cholera. Ten drops 
of the mixture, equal parts, would be the dose for adults, one to 
two drops for children. When the attacks come on more slowly, 
and the evacuations are not yet like rice-water, but yellow, greenish, 
slimy, and attended by griping, tenesmus, cramps in the legs, thirst, 
great anxiety, and restlessness, arsenite of copper 2x should be given 
to adults every half-hour (for children the 3x is sufficient). If the 
cramps in the abdomen are violent, give colocynth or dioscorea in 
alternation. 

Veratrum album is fully indicated during the first and second 
stages. This is the opinion of the late Dr. John Moore, of Liverpool, 
who asserts in his report on the cholera of 1849 that he found the 
mother tincture to act better than the dilutions. Yeratrum album 
does not correspond to the extreme degree of collapse indicating 
arsenic ; for there are few if any records of death from the effect of 
veratrum in poisonous doses, while deaths from arsenic and copper have 
been frequently recorded. Veratrin in doses of one-five-hundredth 
grain every hour (two grains of the 3x) has been used successfully 
when the characteristic symptoms were violent cramps in the lower 
extremities, attended by shocks like those of electricity. In the early 
edition of my " New Remedies," I recommended ricinus communis 
(seeds of the castor oil plant) for cholera, as their poisonous effects 
have a closer resemblance to true cholera than have those of vera- 
trum album. 

Dr. L. Salzer, of Calcutta, in his excellent work on cholera, 
— the best ever written by one of our school, — says he has used 
ricinus very successfully in several epidemics in India. He also 
found it " superior to all other remedies in choleraic diarrhoea." 
Another Indian physician, Dr. Baduri, editor of the " Indian Home- 
opathic Review," reports it " very successful when veratrum failed." 
Both used it in the 3d dilution. 

Dr. Holland, of Bath, England, values iatropha 3x very highly, 
after veratrum failed. The symptoms of iatropha and ricinus are quite 
similar. The oil of cajuput has in India proved useful in cholera, 
especially after it has been kept in copper vessels. In all the stages 
of cholera I do not believe there is any remedy which will give bet- 
ter satisfaction than cuprum-arseniosum. It not only corresponds to 



SPECIFIC INFECTIOUS DISEASES. 105 

nearly all the symptoms which cholera presents, but it has an anti- 
dotal effect on the general condition caused by the bacillus. Unless 
in exceptional, unique, or complicated cases, I believe our success 
will be better if we adhere all through the disease to the use of this 
drug, giving other remedies only intercurrently. 

Some writers have theoretically recommended secale and carbo 
veg. in the stage of profound collapse, but no trustworthy testimony 
has ever been adduced as to their real restorative power. (Theoret- 
ically, Helleborus niger ought to have a curative effect in the coma 
following collapse.) 

Although Dr. Sircar, of Calcutta, asserts that he has seen strik- 
ing benefit from hydrocyanic acid in rapid collapse, I believe arsen- 
icum, aided by phosphorus, glonoine, or aconite, or aconitine one- 
thousandth grain every hour (one grain of the 3x trituration) will do 
all that medicines can do. 

To quench the intense thirst there is no drink so beneficial as 
hot water — as hot as patients can swallow it. They can sip it, or 
drink large quantities. It does not aggravate the vomiting, but 
generally allays it. Cold water may be permitted, but never in 
large quantities. It should be sipped, and can be made ice-cold, or 
small pieces of ice can be swallowed. Injections of hot water 
into the bowels, two or three pints at a time, have been beneficial. 
If aciduated slightly with sulphuric acid better results might be 
obtained. 

Peroxide of hydrogen may possibly prove of great value. It is 
so inimical to all toxic germs and organisms that it may kill the 
comma bacillus outright. I do not know that it has ever been sug- 
gested, but its value should be tested if the usual medicines fail to 
have good effects. 

In the stage of collapse owing to the profuse serous discharges, 
the blood becomes concentrated, and absorption takes place rapidly 
from the lymph spaces. This gives the shrunken, puckered appear- 
ance to the features and skin of a patient in this stage. For this 
condition, Osier and others recommend an intra-venous injection of 
a saline solution. For this common salt should be used, about four 
grammes (one drachm) to the litre (one quart) of pure water, pre- 
viously boiled. (See "Medical Record," Vol. 41, No. 1, Jan. 2, 
1892 ; article by Dr. H. M. Dambarn.) 



106 THE PRACTICE OF MEDICINE. 

" With rubber tubing, a canula from an aspirator, or even with 
a hypodermic needle, the warm solution may be allowed to run by 
pressure beneath the skin. It is rapidly absorbed, and the process 
may be continued until the pulse shows some signs of improve- 
ment." 

This is a valuable method, thoroughly physiological, and should 
be tried. It is said that enemata of salt-water into the bowels has 
been used successfully in the present epidemic in Hamburg, decreas- 
ing the death-rate fifty per cent.* 

The stage of reaction is generally attended by fever. In this 
condition baptisia, gelsemium, and aconite are useful. If an inof- 
fensive diarrhoea continues, salol in doses of two grains every four 
hours is an admirable remedy. The diet during the stage of re- 
action, and during convalescence, should be carefully watched, or 
relapses will occur. Bland farinaceous foods or plain meat broths 
are allowed, but no solid food should be swallowed for some time. 
The food should be often, in small quantities. One of the most 
annoying sequelce is suppression of urine. Turpentine, cantharis, 
and apis are most useful. Drs. Drysdale and Moore recommend 
kali bichromatum, having found it useful. For an extensive his- 
tory of cholera, I refer the reader to Dr. J. P. Dake's excellent 
article in Arndt's " System of Practice," which is worthy of being 
consulted. 

* Since the above was written the following telegram from New York would 
seem to show that salt-water injections would be not only useless but injurious: 

" Dr. Paul Gibier, of the Pasteur Institute, and president of the Bacterio- 
logical Institute, of this city, completed this afternoon an investigation in connec- 
tion with the cholera germs, the results of which put a new phase upon the work 
of preventing the spread of the disease. As a preventive of cholera, salt-water 
bathing has been recommended. Dr. Gibier has been experimenting for some 
time at his laboratory to determine if the cholera germs possess the necessary vitality 
to live in salt-water or the ordinary sea-water. As a result of these experiments 
he conclusively demonstrated that the germs can exist in salt-water a long time, 
for several days at least, and possibly for a week or two. He is, moreover, 
authority for the statement that the cholera germ propagates in salt-water. He 
believes that while existing in the water these germs naturally drift with the 
tides or currents, and coming ashore spread the poison upon whatever they 
attach themselves to. The germs upon which Dr. Gibier has experimented 
have been in his possession some time, and the investigation has been carefully 
conducted." 



SPECIFIC INFECTIOUS DISEASES. 107 



TUBERCULOSIS.— SCROFULA.— PHTHISIS. 

I do not intend in this work to give a comprehensive history, 
etiology, etc., of this disease. Nor shall I pretend to give any cura- 
tive drug treatment, for it can truthfully be said that there is at 
present no medicinal treatment worthy of that name. The disease 
we know under the name of consumption of the lungs and phthisis 
is but a local manifestation of a condition known as tuberculosis. In 
order that you may have a clear idea of what tuberculosis really is, 
I shall summarize the most recent facts (not theories) of all the 
most eminent pathologists. 

Osier (" Practice of Medicine ") is probably the best exponent 
of these facts, and I shall follow him. 

" (1) Tuberculosis is an infectious disease, caused by the bacil- 
lus tuberculosis, the lesions of which are characterized by nodular 
bodies called tubercles, or diffuse infiltration of tuberculous tissue 
which undergo caseation or sclerosis, and may finally ulcerate, or in 
some situations calcify." 

This is a brief, comprehensive statement of the general condition. 
It is one pi the most wide-spread of all maladies. It rarely if ever 
attacks cold-blooded animals, although it has been found in a few 
reptiles in confinement. Among birds and fowls it is very common. 
It is common among ruminants, especially the bovine species. 

" I believe firmly that all the tuberculosis that affects the human 
race is derived from the domesticated bovine, because the only people 
on the face of the earth who enjoy immunity from tuberculosis are 
those who do not harbor domesticated tuberculous animals." (Dr. 
E. P. Brush, " Dietetic and Hygienic Gazette.") 

It is rare in sheep ; common in hogs ; rare in horses, dogs, cats, 
rabbits, and guinea pigs, unless infected by human beings. Apes 
and monkeys in a wild state do not have it, but contract it when in 
confinement. It is found in all countries, but rare near the poles, 
in the high regions of the Alps and Andes, and on the central 
plateau of Mexico. The Rocky Mountains and California enjoy no 
special immunity. No race is exempt from its ravages. The 
aborigines of this country, even in its most salubrious localities, 
suffer from it. The negro race is very susceptible to it. Osier 



108 THE PRACTICE OF MEDICINE. 

gives a very interesting history of the discovery of the bacillus by 
Koch, and ends with this remarkable sentence : "It forms one of the 
most masterly demonstrations of modern medicine. Its thoroughness 
appears in the fact that in the nine years which have elapsed since 
its announcement, the numerous workers at the subject have not, so 
far as I know, added a solitary essential fact to these presented by 
Koch." Osier's history of its mode of growth, products, distribu- 
tion, and modes of infection, is alone a sufficient inducement to every 
physician to study his " Practice of Medicine." He believes there 
is enough testimony to prove that tuberculosis is hereditary, but in 
what way is an unsettled problem. A most curious fact is that the 
" viscera of a foetus born of a phthisical mother were infective to 
guinea pigs." "It is universally conceded," says Osier, "that only 
tuberculous matter can produce when inoculated tuberculosis." 
Gregg, in his presumptuous essay on " Consumption," denies this ; 
but who will accept the mere dictum of a Gregg against the scientific 
opinion of Osier and Koch? 

The ways of infection are innumerable. Men who handle dead 
animals are infected through abrasions in the skin. It may be con- 
tracted from unclean knives which have cut into tuberculous tissues ; 
the wearing of earings once worn by consumptives ; the* bite of a 
tuberculous subject ; washing the clothes of a tuberculous patient. 
It is denied that it can be communicated by humanized vaccine 
virus, but I believe it can when the substance used is not absolutely 
pure vaccine lymph. 

Years ago when the " scab " from human subjects was used, I 
have seen many undoubted cases of infection causing tuberculosis. 
Although it is denied that the expired air of tuberculous patients is 
infective, the statement should be qualified. I see no obstacle 
to the presence of bacilli in the expired air during an attack of 
coughing, and I would not advise one to breathe such forcibly 
expired air. It is not denied that the virus often exists in great 
quantity in the air of cities, hospitals, rooms where consumptives 
live, and especially in railroad cars. I believe the sleeping-car and 
the dining-car to be potent factors in the spread of phthisis. These 
two kinds of cars are often combined, as in the buffet-cars. During 
certain seasons, nearly every sleeping-car running west and south 
contains one or more consumptive patients. If ever so careful some 



SPECIFIC INFECTIOUS DISEASES. 109 

of their sputum gets upon the floor. In a heated car it soon dries, 
especially during the night. In the morning the porter sweeps the 
car, and in the dust that arises are millions of tubercle bacilli; they 
settle upon everything and are breathed in by all the passengers. 
While the infected dust is still floating in the air, breakfast is 
brought in, and the bacilli settle upon the food and are eaten. I 
will not dwell upon this revolting subject, but it impels me to 
caution people not to travel in a car with a phthisical person. It 
may be necessary, when hygiene is better understood by the public, 
to pass a national law which shall require separate cars for the tuber- 
culous or greater care in their management, and perhaps the pro- 
hibition of eating in a sleeping-car. Tuberculosis is very prevalent 
in institutions in which the residents are denied fresh air with a free 
open life, as in numerous cloisters, asylums, and prisons. It is 
believed by investigators that it can be contracted from a tuberculous 
husband by the wife, and vice versa. If one of a family of several 
dies of phthisis, the remainder often die of the same disease if they 
continue to live in the same house ; but if one member leaves and 
resides in another locality, this one escapes. This I have seen veri- 
fied in many instances. The infection may be contained in the milk 
of cows that have tuberculosis. This has been proven beyond a 
doubt. Meat may contain the virus and propagate the disease 
unless thoroughly cooked. But the meat of all animals that have 
tuberculosis should be forbidden to be used as food. I ought to 
mention that Dr. T. H. Mays, of Philadelphia, denies the contagious- 
ness of consumption, and in a paper in the " Therapeutic Gazette," 
March, 1889, brings a vast amount of apparently incontrovertible 
proof in support of his assertion. Dr. Mays also published an essay 
on " The Nervous Origin of Phthisis," alleging the bacilli to be only 
a secondary result. 

Tuberculosis occurs at all periods of life. Its manifestations vary 
at different ages. During the first ten years it attacks the lymphatic 
glands, bones, and meninges of the brain. The cervical glands in 
young children are frequently affected. From the tenth to the for- 
tieth year, pulmonary tuberculosis is most common. The local con- 
ditions which favor tuberculosis are certain soils and localities among 
which are low, damp, poorly drained soils. But in such localities 
catarrhal conditions are prevalent, and catarrhal states of the mucous 



110 THE PRACTICE OF MEDICINE. 

membranes afford the best soil for the implantation of the bacilli, and 
it may be stated as a general fact that the germs of tuberculosis in 
a majority of cases gain entrance to the body through the respira- 
tory organs. 

ACUTE TUBERCULOSIS. 

Osier says, " For practical purposes it may be divided into three 
classes : (1) Acute general infectious ; (2) pulmonary ; (3) cere- 
bral or cerebro-spinal. The acute general infection is often mis- 
taken for typhoid fever, and is with difficulty diagnosed from it. 
The pulmonary may be mistaken for pneumonia, but the meningeal 
form is unmistakable." 

For details of etiology, symptoms, and diagnosis, consult Osier's 
" Practice," and Arndt's " Svstem of Medicine." 



SCROFULA (Tuberculosis of Lymph Glands). 

The definition now given of scrofula is, that scrofula is tubercle^ 
and that the bacillus of Koch is its principal element. If there is 
any difference it is that the virus which produces the chronic aden- 
itis, or scrofula, is of a milder character, a more attenuated form. 
This seems to be proven by experiments. Olser gives as follows the 
principal features of interest in tuberculosis adenitis : 

" (1) The local character of the disease. Thus, the glands of the 
neck, or at the bifurcation of the bronchi, or those of the mesentery, 
may be alone involved. 

" (2) The tendency to spontaneous healing. In a large propor- 
tion of the cases the battle which ensues between the bacilli and the 
tissue-cells is long ; but the latter are finally successful, and we find 
in the calcified remnants in the bronchial and mesenteric lymph- 
glands evidences of victory. Too often in the bronchial glands a 
truce only is declared, and hostilities may break out afresh in the 
form of an acute tuberculosis. 

" (3) The tendency of tuberculosis adenitis to pass on to suppura- 
tion. The frequency with which, particularly in the glands of the 
neck, we find the tuberculosis processes associated with pus is a spe- 
cial feature of this form of adenitis. In nearly all instances the pus 
is sterile. Whether this suppuration is excited by the bacilli or by 



SPECIFIC INFECTIOUS DISEASES. Ill 

their products, or whether it is the result of a mixed infection with 
pus organisms, which are subsequently destroyed, has not been 
settled. 

" (4) The existence of an unhealed focus of tuberculous adenitis 
is a constant menace to the organism. It is safe to say that in 
three-fourths of the instances of acute tuberculosis the infection is 
derived from this source. On the other hand, it has been urged 
that scrofula in childhood gives a sort of a protection against tuber- 
culosis in adult life. We certainly do meet with many persons of 
exceptional bodily vigor who in childhood had enlarged glands." 

The infection may be general, attacking all the lymph-glands of 
the body ; or local, affecting the cervical and submaxillary, popular- 
ity known as kernels : the bronchial and the mesenteric. 



PULMONARY TUBERCULOSIS. 

Three varieties of pulmonary tuberculosis are now recognized : 
(1) tuberculo-pulmonary phthisis ; (2) chronic ulcerative phthisis ; 
(3) fibroid phthisis. Osier says there are two distinct types of 
lesion according to the mode of infection : (1) when the bacilli 
reach the lungs through the blood-vessels, and (2) when the bacilli 
reach the lungs through the bronchial tubes by inhalation. 

Those who desire to consult the most recent facts of the pathology 
and diagnosis of this disease should consult Osier's work, which is 
now generally accepted by specialists. If the bacilli are not found 
after repeated examination by a competent microscopist the disease 
is not true tuberculosis. In such cases the malady may be chronic 
bronchial catarrh or simply fibroid phthisis. Sir Andrew Clark, in 
a lecture on fibroid phthisis recently delivered at the London Hos- 
pital, said: "It has been alleged by Koch, and it is generally 
believed in London, that every case of phthisis, as I have defined 
it, is microbic, and associated with and dependent upon the presence 
and the action of tubercle bacilli. For my own part I presume to 
deny the allegation, and to contend that while the great majority of 
cases of phthisis are bacillary, there is a considerable minority of 
cases which are non-bacillary, in which at no period in their history 
can bacilli be found." The prognosis in tuberculosis has always 
been gloomy, except by charlatans, who for commercial purposes 



112 THE PRACTICE OF MEDICINE. 

claim its curability by medicines. I do not deny the curability of 
phthisis, but I do affirm that the cures by drugs alone are exceed- 
ingly rare. Indeed, spontaneous cures are much more frequent 
than medicinal. Many years ago, Flint called attention to the self- 
limitation and intrinsic tendency to recovery in well-marked cases of 
pulmonary tuberculosis. Of his 670 cases, 44 recovered, and in 31 
the disease was arrested ; spontaneously in 23 of the first group, and 
15 of the second. Osier says, " In many cases a natural or spon- 
taneous cure is effected, for the conditions favorable to the develop- 
ment of the disease are not present — in other words, the tissue-soil 
is unsuitable." Now, if we can find out how to render the tissue- 
soil unsuitable, we shall advance one step towards the discovery of 
a means of cure. 

The duration of pulmonary tuberculosis is very variable. Laen- 
nec says two years, and this is as nearly correct as can be arrived 
at. Pollock's 3,500 cases show the average duration to be about 
two and one-half years. The question of marriage of tuberculous 
subjects may become in time regulated by law. When a man or 
woman has a cough with fever, and bacilli are discovered in the 
sputum, marriage should be forbidden, at least until the bacilli or 
other local signs of tubercle have disappeared. A man or woman 
who has a family history of tuberculosis should not be permitted to 
marry. Child-bearing increases the risk. Pregnancy, contrary to 
the opinion held several years ago, does not prevent phthisis. It 
may cause an apparent arrest, but the disease is pretty sure to resume 
its sway after parturition. 

The prophylaxis of tuberculosis is a momentous question. If the 
children of tuberculous parents grow up delicate, pale, narrow- 
chested, and with enlarged lymphatic glands, they should be removed 
if possible to some climate noted for its antagonism to phthisis. If 
one of such family dies of phthisis this separation becomes imperative 
if any of them are to be saved. A mother with pulmonary tuberculosis 
should not suckle her child. It should not only have a healthy wet- 
nurse, but should be removed to a healthy locality and guarded against 
all catarrhal affections. If the child has " mouth breathing," any 
adenoid vegetation of the naso-pharnyx, or nasal passages, should be 
removed. The child should be clothed in all-wool underwear and 
kept in the open air as much as possible. Frequent bathing with 



SPECIFIC INFECTIOUS DISEASES. 113 

soap and water is injurious, but cool rapid sponging of the chest and 
neck is beneficial. If the skin is dry and rough, the child should be 
rubbed all over with oil twice a week. The feeding should be regu- 
lar, and consist mainly of Pasteurized milk, cream, butter, and bacon 
— to the exclusion of sugar, candy, cake, and all delicacies of an 
indigestible nature. Such children have a decided aversion to all 
fat, as fat ; but it can be put into many articles of food, and made 
attractive and palatable. Butter nearly all children will take, on 
potatoes, bread, and in various forms. In my experience very few 
dislike well-cured and well-cooked bacon. 

As tuberculous poisons pervade the sputum and many other excre- 
tions, all these emanating from such patients should be disinfected 
or destroyed as soon as possible. The sputum should be expector- 
ated on cloths and burned, or into portable spit-cups, many kinds of 
which are now for sale by all druggists. There should be no spit- 
ting on the floor. All handkerchiefs should be boiled before the 
sputum on them becomes dry ; all sheets and underclothing in contact 
with the skin should be frequently changed and boiled, as the sweat 
of consumption has been found to contain bacilli. The body should 
be washed every day with hot water containing creoline, lysol, or 
some bacillicide. No one should kiss a consumptive, especially on the 
lips — there is danger in such contact. 

Regarding the natural or spontaneous cure of phthisis, Osier 
makes the following assertion : " The spontaneous healing of local 
tuberculosis is an every-day affair. Many cases of adenitis and dis- 
eases of the bones or of the joints terminate favorably without the aid 
of medicines. The healing of pulmonary tuberculosis is shown, clin- 
ically, by the recovery of patients in whose sputum elastic tissue and 
bacilli have been found ; anatomically by the presence of lesions in 
all stages of repair. In the granulation products and associated 
pneumonia a scar-tissue is formed, while the small caseous areas 
become impregnated with lime-salts. To such condition alone should 
the term healing be applied." 

We may ask, in view of these facts, why cannot we find some 
way to imitate Nature's cures ? 

Medicinal Treatment. — Almost every known drug of great power 
has been recommended, but, tried, has failed to cure tuberculosis of 
the lungs. The enumeration of half of them would fill pages of this 



114 THE PRACTICE OF MEDICINE. 

book. One of the most astounding things connected with these 
medicines is their rapid rise in favor, and their rapid fall. It is a 
puzzle why eminent medical savants, after using a particular drug 
for a short period, burst out in fulsome encomiums, lauding its cura- 
tive powers, when after a few months or years they themselves are 
the first to discard them. This has been the history of the use of 
arsenic, iodine, iodoform, eucalyptus, tannin, hypophosphate, cod- 
liver oil, mineral oils, gold, manganese, creosote, etc. 

Of all these drugs creosote still holds its own against the rest, in 
the old school. Some very favorable reports have appeared during 
the last few years. In many cases there were apparent cures. In 
many great improvement. How many veritable cures have been 
made is not known. In 101 cases under the care of Meredith Reese 
in Osier's clinic its chief action was on the cough and expectora- 
tion, but the remedy according to Osier " had no essential influence 
on the disease." Many reports in the " Medical Record " and other 
journals of this country and Europe are more favorable, but the 
time for trustworthy data has not yet arrived. I have used it in ten 
undoubted cases of tuberculosis phthisis, in which it lessened the 
sputum and the fever, but did not cure in a single case. I gave it 
as recommended by old-school authorities, beginning with one drop 
three times a day, increasing a drop each day until ten drops were 
given three times a day. I have also tried the dilutions from the 
lx to 3x, but the smaller the dose the less improvement was per- 
ceptible. It doubtless acts by passing into the circulation, and is 
transported through the lungs, as are the volatile oils (oleo-resins?), 
iodine, etc. The " Shurley-Gibbes" treatment with gold and iodine 
aroused at one time a good deal of hope, but it has not sustained 
its early promise, and will soon drop into obscurity. The later 
" gold and manganese " treatment will share the same fate along 
with the Bergeon's and Koch's method. The subsidence of Koch's 
tuberculin is one of the saddest episodes in the history of thera- 
peutics. 

At one time it was reported that if consumptive patients inhale a 

icrobe which was so inimical to the bacilli that it would destroy 

them, the said microbe, being a harmless one, would remain without 

injury ; meanwhile the patient is cured. Another physician treated his 

consumptive patients by causing them to inhale air at a temperature 



SPECIFIC INFECTIOUS DISEASES. 115 

of 150° F., the air at that temperature being found destructive to the 
bacilli. Then it was proposed to have patients inhale bacillicides, 
such as the mercuric chloride, creosote, carbolic acid, etc., but it was 
found that these inhalations were more dangerous to the patient than 
to the bacilli. The oxygen treatment and the pneumatic cabinet 
have also had their day. 

Homeopathic Treatment. — In 1859 Dr. William Hitchman wrote 
a little treatise on Consumption. It was very readable, and the clin- 
ical reports showed that several of our medicines, notably stannum, 
lycopodium, kali carb., zincum, sulphur, etc., had cured cough with 
quite serious pulmonic symptoms. But a careful examination of the 
cases showed that true pulmonary tuberculosis was not among them. 
Great stress was laid upon the cures of stannum, but the disease 
cured by that remedy would now be called purulent bronchitis. 
The cures by kali carb. were cases of bronchitis with intercostal 
myalgia; those by lycopodium were cases of chronic pneumonia. 
From time to time reports of cures of consumption have appeared in 
our journals, but no testimony was presented showing that the cases 
were due to tuberculosis. Many of the reports were cases that were 
sent to some salubrious climatic resorts, while they were taking the 
medicines prescribed. Such reports are worthless, as no credit was 
given to the climate which probably was the curative agent. 

In 1890 Dr. W. H. Burt wrote a work on " Tuberculosis, or 
Pulmonary Consumption: Prophylaxis and Cure by Sur- Alimenta- 
tion of Liquid Food." An examination of the book shows that the 
collected data extended over a brief period only, and that the num- 
ber of cases is insufficient to prove the value of the treatment. It 
is not denied that sur-alimentation is a potent factor in the preven- 
tion and cure, but it requires a larger experience to place it upon a 
scientific basis. 

Dr. Burt's book is a store-house of suggestions relating to diet. 
He enumerates all the foods and beverages which are likely to be of 
benefit to the consumptive, and a great many of doubtful value. He 
insists mainly on a fluid or semi-fluid diet, and that food should be 
taken frequently. He truthfully says that the diet of consumptives 
should be just the opposite of that recommended for corpulence. I 
agree with him, except that both should eat pure animal and vege- 
table fats. His indications for medicinal remedies are excellent, 



116 THE PRACTICE OF MEDICINE. 

and in some respects better than those given by Dr. H. C. Allen, 
with which they should be compared. 

In 1892 was published a posthumous work written by Dr. Gregg, 
edited by Dr. H. C. Allen. The publication of Dr. Gregg's theories 
under the sanction of a prominent member of our school is very 
unfortunate. Although the theories are accepted by very few, the 
whole homeopathic school will be saddled with it. The theories are 
so grotesque, and so at variance with the facts now established and 
accepted by the whole scientific medical world, that it is a source of 
humiliation to us. Had Dr. Allen left Gregg's theories out, and 
called the book " Indications for the use of palliative remedies in 
Consumption," the work would have had a lasting popularity, and 
redounded to his credit. Dr. Gregg opens his work with the fol- 
lowing startling announcement : " Having finally secured the last 
link in the long chain of positive as well as negative proof to clear 
up the mystery which has so long hung over the cause and nature of 
tubercle, I am now prepared to re-affirm even more positively than 
ever before that the cause of consumption is a loss of albumen from 
the blood through irritated and abraded mucous membranes." 

He cites Bright 's disease as proof. Further on he says : " The 
blood corpuscles left in excess are decolorized by circulating in the too 
watery blood or serum, notwithstanding the night-sweats, and dropsy 
throws off a large portion of the excess of water, and these decolorized 
corpuscles are then deposited in the capillaries, where they shrivel to 
become the so-called tuberculous corpuscles which are organized into 
tubercles and which have no other origin but this." In another place 
he denies the existence of the tubercle bacillus, and declares that the 
objects so called are nothing else than "short sections of threads of 
fibrin broken up under the slow rotting of the tubercle." To support 
this he brings forward many subtle and ingenious arguments, which 
seem to the unscientific ample proof, and which I shall not attempt 
to controvert. 

His treatment is this : If we can arrest the flow of albumin from 
mucous surfaces we can cure consumption. The second part of the 
book is written by Dr. H. C. Allen, who, after giving excellent rules 
relating to hygiene, diet, and climatics, gives indications for nearly all 
the remedies in our materia medica, one hundred and seventy ; not 
one of which has ever cured a case of consumption. They are all pal- 



SPECIFIC INFECTIOUS DISEASES. Ill 

liatives, useful when indicated, but have no actual curative power over 
this dread disease. The Repertory is well written, and is a work 
showing great and patient labor. The whole book is a monument 
of misdirected industry, interesting, even fascinating, but based on 
fallacious theories, and, except as relates to the cure by diet and cli- 
mate, is unpractical and valueless. I do not desire to place myself on 
record as denying the possibility of curing pulmonary tuberculosis 
with medicines, but I do deny the probability of cures made without 
changing the hygienic and climatic surroundings of the patient. I 
also assert that a favorable change in the environment of the patient, 
especially in the incipient and early stages, will cure more than any 
other agency. 

The Climate for Consumptives. No one climate will suit all 
cases. It is not pure air, sunshine, altitude, equal temperature, cold, 
or heat alone that makes a climate for consumptives, but a careful 
blending of a part of these conditions. A climate and locality that 
will arrest the disease in one, will hasten its progress in another. 
Before sending a patient with pulmonary tuberculosis to any cli- 
mate he should be told that if the locality selected does not cause 
improvement in a reasonable time, another and different one should 
be visited. The advice of Dr. B. W. James in his " American Resorts 
and Climates " is so pertinent and good that I quote it. He says : 

" When a sufferer from phthisis has found a climate suitable for 
his individual case, and repaired to it, he should remain, if not per- 
manently, which is the best plan as a rule, at least until his health is 
well established, and after leaving, should he notice a return of his 
lung difficulty, go back at once to the favorable climatic conditions. 
If this desirable climate is prescribed by his attending physician the 
prescription should be accompanied by a letter of introduction to a 
reliable physician at the place of resort, which communication should 
contain information in regard to the patient, the history of his 
malady, past treatment, and other guiding-points in the case. From 
considerable observation we are persuaded that as a rule cases of 
pulmonary phthisis that have reached the last stage of the disease, 
reap longer life, enjoy more comfort, obtain more kindly care, and 
suffer less, by a continuance at their home, if it be a comfortable 
one, than they do by a residence at an invalid resort, no matter 
how near at hand the locality may be. Not infrequently, where a 



118 THE PRACTICE OF MEDICINE. 

number of such cases are stopping at the same hotel, they will greatly 
annoy each other ; disturbing their rest at night by coughing, and 
add to each other's discomfort during the day by gloomy and 
depressing conversation." 

Dr. James further says it is his experience that " In the majority 
of cases a dry climate is desirable, and as a rule one not having a 
very high range of atmospheric temperatures ; to these conditions 
may be added (for the patient not suffering from hemoptysis or fee- 
ble heart) that lessened barometric pressure obtainable in high lat- 
itudes. In short, we believe that a pure, clear, dry, cool, rarified 
atmosphere is desirable for most phthisical cases." 

There are many cases of phthisis and other pulmonary disorders 
that do not do as well in a cool climate, even if it is dry, and in a 
damp climate they are not only uncomfortable, but are made worse 
by it. Such cases do well in a warm dry climate, in which they 
experience less discomfort, and rapidly improve. This I have veri- 
fied in several patients who went to California and got worse while 
on the coast, but when they changed to the eastern slope, to Ban- 
ning, immediately improved. I recall one case, a young married 
woman of this city, who had intestinal and pulmonary tuberculosis. 
She grew rapidly worse at Los Angeles and Santa Barbara, but at 
Banning she improved rapidly. She remained there two years, when 
the heat seemed to debilitate her. She removed to El Paso, Texas, 
where she improved for several months, when an arrest of improve- 
ment caused her to go to San Antonio, where she was greatly bene- 
fitted during the winter, but in the spring the heat affected her so 
unpleasantly that she went to Colorado Springs, where she now is. 
She writes me that she has fully recovered. Allow me to say that 
even now I doubt the propriety of her return to Chicago. 

Very few cases continue to improve many years after their return. 
Sooner or later the latent tuberculosis manifests itself. I recall a 

case that came under my observation in Florida. Colonel B came 

to Enterprise from northern New York, in the suppurative stage of 
phthisis, nearly twenty years ago. During his first winter he improved 
so notably that he purchased an orange grove on the shore of Lake 
Monroe, where he lived in comfortable health until 1891. He had 
occasionally spent three months in the summer at his Northern home, 
but always hurried back to Florida before October. On his last 



SPECIFIC INFECTIOUS DISEASES. 119 

visit he remained six months in the North ; too long for safety, for 
his cough, expectoration, and hectic returned in September, and he 
died in November, before he could reach Florida. This is but one 
example in thousands which illustrate that if patients go to a climate 
which arrests the disease, they should remain there. There is no 
safety in returning to their Northern homes. One reason why con- 
sumptives should never return to their Northern homes is mentioned 
by Dr. R. Thorne in " Sajous' Annual." He says : "A house in which 
the disease has existed remains a centre of infection for an indefinite 
time." The western slope of California has been greatly overrated 
as a resort for consumption, or for any chronic bronchial or pul- 
monary disease. Only in the extreme southern and southeastern 
part do we find the climatic conditions favorable ; but these localities 
are almost unpopulated, and patients cannot be made physically 
comfortable there. Take it all in all, probably the section of country 
possessing the most beneficial climate west of the Mississippi for 
consumptives generally is what Dr. Littlejohn calls the Rocky Moun- 
tain Region. This he defines as follows : " The elevated section of 
country amid and on the sides of the Rocky Mountains extending 
from El Paso, Texas, or the Southern line of New Mexico, north 
through the whole of New Mexico, Colorado, and into Wyoming." 
Dr. Littlejohn, himself an invalid, travelled all through that region, 
and noted its effects on hundreds of phthisical persons. I should 
include Arizona, which I believe will in time, when settled, be the 
chief sanitarium for consumptives in the West. Dr. E. J. Clark, of 
Denver, writing of the causes of phthisis, says : " Tuberculosis is 
produced primarily by a process of malnutrition and consequent lack 
of energy of the organs of circulation and excretion." Dr. Richard 
Hughes has well said: " Certainly the most important medicines for 
tuberculosis are those which influence the assimilative process. 
Therefore, as malnutrition must be overcome, the question of assim- 
ilation, even from a climatological standpoint, becomes one of great 
importance. Healthy persons, and most invalids who have a moder- 
ate amount of energy, at elevations of less than 6,500 feet find an in- 
crease in the appetite for food. Some of the feebler class, especially 
those who habitually have a better appetite for food in warm than in 
cold weather, find a diminution in appetite on first going to elevated 
regions when only an altitude of 4,000 or 5,000 feet is reached. 



120 



THE PRACTICE OF MEDICINE 



This loss may be only temporary or it may be persistent. How often 
I hear patients say, ' I cannot get enough sleep or enough to eat.' 
When I hear this, I know that the patient is gaining. An improve- 
ment in the general nutrition of the body and in the quality of the 
blood is usually produced by mountain climates, and nervous and 
muscular energy are increased. It would only be natural that, in a, 
bright and dry and light atmosphere, with nature rejoicing in the 
cheerfulness of a healthy climate, that not only the heart's action 
and respiration should be increased, but that, the blood flowing free 
through the entire body, no stagnant pools anywhere, and tinged 
with the bright and rich color that only the God-given sunshine can 
give it, the whole body should rejoice and assimilation take a stride 
forward. In a climate filled with moisture, the density of the air 
weighing down the system, clouds hiding the light of the sun and 
gloominess and moisture predominating, should we be surprised that 
the body should be also sad and assimilation falling away ? " * 

The next important region is what might be called the Alle- 
ghany Region, which includes the sections amid and on both sides 
of the Alleghanies, preferably the western slope, from Ashville, N. 
C, through South Carolina and Georgia. The third region, which 
is principally for residence during the summer, is the Adirondac 
Region, and the high lands around Lake Superior and in Montana. 
Even in winter, patients may do as well in these regions as in Daroa 
and the Engadine in Europe, and there are places in Yellowstone 

* Dr. Clark makes the following comparison, which places Colorado among 
the best of climates : 

Colorado Climate. 

1. Elevation. 

2. A large amount of sunshine. 

3. Dry air. 

4. A warm sun temperature. 

5. A somewhat variable temperature; 
cool not cold in mid- winter; cold 
during a winter's night, but com- 
fortable at mid-day. 

6. Moderate motion of the air, with 
occasional high winds. 

7. A small snow and rainfall. 

8. The absence of fogs. 

9. A pure air. 
10. A dry, sandy, well-drained soil. 



Model Climate. 

1. Elevation. 

2. A large amount of sunshine. 

3. Dry air. 

5. Variability of temperature. 



6. Moderate winds. 



8. Brightness of the atmosphere. 

9. Pure, aseptic air. 
10. A dry soil. 



SPECIFIC INFECTIOUS DISEASES. 121 

Park which possess a climate in winter that rival them for dryness 
and coldness. Dr. Doran, an English scientist, insists that the day 
will come when all these resorts will be abandoned on account of the 
presence of bacilli, and that then the arctic regions will become 
the only safe resort. 

Dr. B. W. James mentions Florida, and says its mild and moist 
climate is soft and sedative, and useful where there is considerable 
inflammation and dry cough, etc. He mentions Jacksonville, Fer- 
nandina, and St. Augustine, as the " most popular." This popularity, 
however, is confined to tourists, but these places are the worst in 
all Florida for phthisis and nearly all pulmonary diseases. In the 
following paper read before the American Health Association, I 
reported what I believe gives a true estimate of the climates of 
Florida : 

" It will be observed that I use the plural in speaking of the cli- 
mate of Florida. I do this because it is as improper to speak of the 
climate of that state as it would be to speak of the climate of the 
United States. 

When the physician sends a patient to Florida for his or her 
health, and does not specify the part of the state his patient ought 
to go, he shows a lamentable ignorance of that state, for Florida has 
several distinct climates, and that portion of the state which is good 
for one patient may be injurious to another. It is the general 
belief among the laity, and most of the medical profession, that the 
whole of the state of Florida is low, damp, and malarious. Now 
this is not true. It only applies to one or two sections of the state, 
as I shall try to show you on the outline map which I place before 
you. You will observe that I have divided the state horizontally 
into three divisions, namely : 

Upper Florida, reaching from 31 degrees to 29 1-2 degrees of 
latitude, 

Middle Florida, from 29 1-2 degrees to 27 1-2 degrees, and 

Lower Florida, from 27 1-2 degrees to 25 degrees, or nearly to 
Key West. 

Now when I tell you that each of the above divisions represents 
a quite different climate you need not be surprised. 

Upper Florida is like Georgia and Alabama, where frosts and 
snows are not infrequent, and cold northwestern and eastern winds 



122 THE PRACTICE OF MEDICINE. 

in winter are quite trying to any invalid. The fruits of this region 
are different from the other divisions. There is no doubt that every 
decade or century the whole upper half of Florida is growing colder. 
Oranges, lemons, bananas, and figs once grew as far north as Charles- 
ton, S. C, and St. Augustine was once the centre of the orange- 
growing region. Now the orange is a failure north of Jacksonville, 
and an uncertain crop in the latitude of St. Augustine and Cedar 
Keys. 

But in this region the pear, peach, grape, and plum grow and 
reach their greatest perfection. The mean temperature of this region 
in winter is 60° and in summer 80°. Now it is evident that we cannot 
send all patients to this climate in winter. Those who are troubled 
with rheumatism, pulmonary disorders, catarrh, and bronchitis do 
not do well here. The change in temperature from noon till evening 
is great, and the sudden coolness that comes with the dark is dan- 
gerous to patients with sensitive lungs, unless they take excellent 
precaution and keep in-doors, in a temperature as nearly that of the 
day as is possible. In this region a fire in the stove or fireplace in 
the evening is indispensable from the first of November until the 
first of April, and during the prevalence of " northers " patients 
should not stay out-of-doors. 

In Middle Florida the mean temperature in winter is 70° ; in 
summer, 80° to 85°. The northers are not as severe, especially 
inland, and the nights are warmer, but the same precautions should 
be taken during the winter months, for the fall in temperature from 
5 to 9 o'clock p. m. is often 10°. Often in winter the heat of the 
sun from 10 A. M. to 3 P. M. is intense. I mean the direct rays of 
the sun, for if you are in the shade of a tree, or under an umbrella 
or a piazza, you do not feel the heat. Many patients catch cold in 
Florida from ignorance of this fact. They walk in the sun and get 
heated and perspiring, sit down in the shade, and soon find they feel 
chilly, and the result is an illness. This climatic peculiarity is not 
confined to Florida, but belongs to Mexico, California, New Mexico, 
Spain, Italy, and even Algeria. I think in no part of the world did 
I feel the evening change so unpleasantly as in California on the 
Pacific slope. In Cuba and Jamaica and the Bermudas the change 
at night is not so abrupt and very much less. In Cuba in January 
and March it is scarcely felt, the thermometer not dropping more 



SPECIFIC INFECTIOUS DISEASES. 123 

than 4° at night. Not all of middle Florida has this sudden cool 
change in the evening, for there is a portion on the Gulf coast that 
is more even in temperature, because there is less average humiditj^ 
in the air ; but I shall refer to this further on. This middle Flor- 
ida is the orange-belt, where that fruit grows to perfection. It 
reaches from Palatka to Charlotte Harbor. The lemon, lime, and 
grape-fruit grows in this region, particularly below the 28th degree 
of latitude ; above that it is sometimes injured by frosts, for they are 
more sensitive to frosts than the orange. The grape does well in 
this region, and the prospects are that certain portions of it will 
become a profitable wine-producing country. Below the 28th, 
peaches, pears, and plums do not grow as well, and their cultivation 
is unprofitable. But the fig, guava, and pomegranate are success- 
fully grown. In the drier portions of middle Florida nearly all 
patients with catarrhal troubles, bronchial and pulmonary disorders, 
rheumatism, neuralgia, and Bright's disease are very much bene- 
fited in winter, and also in autumn, summer, and spring ; but at all 
times of the year they should avoid the low lands, the borders of 
rivers unless high, and the swampy sea and gulf coast. 

Lower Florida is essentially tropical, nearly as much so as the 
West Indies. The winters are warm and delightful. The heat in 
the middle of the day sometimes reaches 85° or 90°, but the nights 
are not as cool as further north, rarely cooler than 70°. Consump- 
tives will find the Atlantic coast from Rockledge to Bisayone Bay, 
and the gulf coast from Tarpon Springs to Ft. Myers and beyond, 
a climate in winter which is as near perfect as any found in the 
United States. Some consumptives will find the interior of the 
state to agree with them better, but such location is difficult of access 
now, except along the line of railroad from Sanford to Tampa. In 
this favored region is the paradise for neursesthenics ; for nerveless 
and nervous men and women, broken down in mind and body from the 
intense strain of business and social demands in our Northern states. 
The soft languorous air lulls them to sleep at night, and soothes them 
by day. 

There is no region of the United States that can compare with 
this, unless it be some quiet, warm valleys, low lying on the east- 
ern slopes of California, Arizona, or New Mexico. In the regions 
above named most of the semi-tropical fruits grow. The pineapple, 



124 THE PRACTICE OF MEDICINE. 

cocoanut, paw paw, cherimoya, grape-fruit, bananas, and many others 
found in the West Indies and Central America, can be successfully 
cultivated. Injurious frosts do not occur in this region more than 
two or three times in a century. 

Northern people have an idea that the whole of Florida is 
malarious ; this is an error. Florida is no more malarious than 
many Northern states, — in fact, not as malarious as Missouri, New 
Jersey, or Connecticut ; and where it is malarious the type of fever 
is not as severe as in the above states. In the winter, from 
November to May, there is no swamp malaria at all. Tourists and 
winter visitors often contract a disorder which they think malaria, 
but it is not. It is the result of two causes, namely, exposure to 
night air and to the bad sewerage of some Florida hotels. Many of 
the hotels in Florida are wooden structures, put up in a hurried 
manner, and with but little regard to hygienic principles. The same 
may be said of many of the hotels in California and all other parts 
of the United States. Improper eating and drinking at these hotels 
is a common cause of the so-called malarious fevers. 

When you send patients to Florida, tell them to avoid the mar- 
gin of these rivers ; to avoid exposure to sudden changes of temper- 
ature, and all excesses in eating and drinking, or residing in low, 
damp houses. In studying the topography of Florida, there will be 
found an elevation composed of pine lands, called high rolling pine 
lands, midway between the St. Johns River and the Atlantic coast. 
This land is elevated thirty to forty feet above the river and the 
Atlantic. On the western side of the St. Johns River, midways 
between the river and the Gulf, is a prolongation of the Alleghanies, 
extending almost down to Tampa, and at places nearly to the Gulf. 
This " ridge " is elevated in some places two hundred and often four 
hundred feet above the sea. It is on these ridges, on both sides of 
the St. Johns, that patients of all kinds should go on account of the 
dryness of the air, the influence of the pine forests, and better facil- 
ities for house and village drainage. 

On examination of the War Department weather maps, you will 
see that the humidity of Florida is the same as the whole Atlantic 
coast as far north as Maine. But the humidity or dampness of an 
atmosphere is greatly modified by sunshine. Now the weather maps 
show that the mean cloudiness in Florida in winter is about the same 



SPECIFIC INFECTIOUS DISEASES. 125 

as California, which makes the dampness of the atmosphere relatively 
less than any other part of the United States, except California, 
New Mexico, and Arizona. 

A curious feature of the climate of Florida is that the most 
sunny portion of Florida is on the west coast. That area is repre- 
sented by a segment of a circle bending eastward, and reaching from 
Tarpon Springs to Charlotte Harbor. This area is as dry as the 
California coast. But, admitting that Florida is not as dry as the 
Pacific coast, it is no objection to that state. Dryness of the air is 
not always a desideratum in disease, as anyone who has sent patients 
to the dry regions West can testify. Sunshine is of more importance 
than dryness in consumption and in all nervous diseases. It is an 
indisputable fact that a dry climate is not always favorable to recov- 
ery in cases of consumption and all diseases characterized by nervous 
eretheism and pain. Excessive dryness aggravates neuraesthenia, 
chorea, neuralgia, and similar disorders. Some cases of rheumatism, 
bronchitis, and phthisis do better in a moderately damp climate, pro- 
vided there is abundance of sunshine. 

Dr. Dennison does injustice in his map of relative dryness, 
when he gives Jacksonville, Fla., as representing Florida. The fact 
is that Jacksonville is the dampest place in the state, except Pensa- 
cola. St. Augustine, Deland, Enterprise, Tarpon Springs, and 
Tampa are all drier than that city. 

I will make one more observation, and that is relating to Flor- 
ida as a sanitarium for children. For many years I have sent infants 
and children to that state in the winter, and have not in a single 
case had cause to regret it. Our Northern winters are very injurious 
to delicate children. They suffer with catarrhal affections, not only 
of the air-passages but of the intestinal tract. They have croup, 
bronchitis, tonsillitis, indigestion, diarrhoea, and all the disorders 
arising from intestinal and gastric catarrh. They become so sensi- 
tive to cold and dampness that they are deprived of sunshine and 
open air. They grow pale, emaciated, feverish, and fretful. If you 
send such children to the high lands of Florida, or its sea and gulf 
coasts, you will be surprised at the rapid improvement. In a few 
weeks they will be able to stay out-of-doors all day, and eat almost 
anything with impunity. They should not be allowed to return 
North before the month of May. If they begin to feel unpleasantly 



126 THE PRACTICE OF MEDICINE. 

the warmth of April, — which they rarely do, — they should return 
north as far as Aiken, S. C, or Hot Springs, N. C. 

In this brief paper I have given you the results of my experi- 
ence and observation of ten years. I shall be gratified if I have 
given you a better estimate of the climates of Florida. 

How to get to Florida winter resorts. — If the invalid from any 
Northern state wants to go to some place* in Florida, he must first go 
to Jacksonville, unless he starts from a Northwestern state, in which 
case he goes to Mobile or Pensacola or Tallahassee. If he desires 
to go down the east coast, beyond St. Augustine, he takes a river 
steamer on the St. Johns, goes to Sanford, and thence to Titusville 
on the Indian River. The most salubrious places on the east coast 
are St. Augustine, Daytona, Rockledge, Merritt's Island, Melbourne 
Beach, and Lake Worth, which is as far as an invalid can go. The four 
latter places should be visited in December, January, and February. 
In March and April they are too warm for some patients, who feel 
better in Daytona and St. Augustine. Inland, the best resorts are 
Enterprise, Winter Park, and Orlando, which are reached by the 
railroad from Sanford. Children are very favorably influenced by 
the sea-air on the coast, at the places I have named. 

The best resorts on the west coast are Tarpon Springs, Sunder- 
land (which Dr. W. C. Richardson, of St. Louis, considers the most 
healthful), Tampa, Pine Island (a lovely place, with a shore strewn 
with sea-shells), and Ft. Myers (which should not be visited after 
March 1). If we send patients from the North for a radical change 
in climate, and if they need warm, sunny days all the time, start 
them off in December, and tell them not to stop till they have reached 
Rockledge on the east, or Tampa on the west, and remain there or 
beyond until March 1 . Then move northward to Sunderland, Gaines- 
ville, St. Augustine, or Tallahassee, and in April to Thomasville or 
Aiken, contiguous resorts. The inland places on the west side of 
the St. Johns River are Gainesville, Ocala, Leesburg, or any other 
point where the land is high rolling pine. Invalids cannot depend 
on the advice of local physicians, who cannot help being selfish ; it 
is human nature. The best judges are impartial observers, with no 
local interests. " 

Before leaving the subject of Climate I will present the views of 
Dr. Charles Dennison of Denver, whose investigations of this subject 



SPECIFIC INFECTIOUS DISEASES. 127 

makes him our most competent authority. In a recent paper on 
"The Most Preferable Climate in Consumption," he claims to deduce 
from clinical evidence, that the following conditions are the best to 
arrest chronic pulmonary disease : 

1. Dryness as opposed to moisture. 

2. Coolness or cold preferable to warmth or heat. 

3. Rarefaction as opposed to sea-level pressure. 

4. Sunshine as opposed to cloudiness. 

5. Variability of temperature as opposed to equability. 

6. Marked diathermancy of the air to be preferred to the smoky atmosphere 
of cities or the dense air strata of moist currents. 

7. Radiation and absorption of heat by rocks and sandy loams better than 
latent absorption by water and damp clay soils. 

8. Mountainous configuration of country (quick drainage) contrasted with the 
flatness, etc., of level sections. 

9. Frequent electrical changes of atmosphere, also moderate winds (except in 
quite cold weather), preferable to continuous stillness of the air. 

10. Inland altitudes contrasted with sea air (total absence of land influence) ; 
but in certain cases sea voyages and island resorts to be preferred as compromise 
substitutes for high altitudes. 

Dr. Dennison makes a good argument in favor of his preference, 
and I advise all physicians to study his valuable paper. 

One of his arguments in favor of cold, namely, that the bacilli cease 
to grow at a temperature below 82° F., seems undemonstrable, since 
the mean temperature of the New England States, where the percent- 
age of consumption is greatest, falls below that point. The fact is, 
and Dr. Dennison is probably aware of it, that all the favorable con- 
ditions should be combined to make a perfect climate. But suppose 
all these conditions are combined, the matter of soil as a factor 
should not be forgotten. Many high regions possess nearly all Dr. 
Dennison's favorable conditions except soil. I have found that the 
Alleghanies north of Asheville, N. C, possess a damp clay soil. I 
suppose there are portions even of the Rocky Mountains where the soil 
is damp. It is no unusual thing to find marshy spots on the sides or 
tops of the highest mountains. But of course Dr. Dennison would 
not advise such localities. This leads me to suggest that possibly 
Dr. Dennison is not aware how nearly certain parts of Florida come 
to his ideal soil, which is " a dry sandy loam, with rapid absorption 
of air, vapor, and radiation of heat." This is the kind of soil which 
abounds in middle Florida, i. e., from Palatka to Tampa, midway 
between the St. Johns River and the Atlantic on one side and the 



128 THE PRACTICE OF MEDICINE. 

Gulf on the other. These sections are fifty to one hundred feet 
above the sea level, and the soil is almost pure sand, and from ten 
to twenty feet deep, lying upon clay. The porosity of this soil is 
unequaled, and its radiating power immense. The heaviest rains, 
lasting for days, leave the soil wet for only a few hours, the moist- 
ure being rapidly drained and radiated. The mean temperature 
of this portion of Florida from November 1 to April 1 is below 70° 
(when the bacilli, according to Koch, do not thrive). The humid- 
ity of the air in this region is less than that of any other part of 
Florida. During these months in the winter of 1891 there were but 
15 cloudy days out of the 121. On these high sandy hills the air is 
as clear and pure and as laden with balsamic odors as any place in 
the United States. Dr. Dennison gives the following as contra-indi- 
cations or " general reasons why a given invalid should not go to an 
otherwise high climate," and those are the patients who should go 
to the region in Florida above mentioned. Dennison's contraindi- 
cations are: 

1. The coldest season of the year, intensifying the effect of altitude too much 
for those coming from warmer climes. 

2. Advanced age of the individual, rendering acclimatization difficult; senile 
phthisis; and those who are too old and feeble to exercise out-of-doors. 

3. A very excitable, nervous temperament, aggravating the stimulation of 
climate, producing irritability and sometimes wakefulness. " Erethric phthisis." 

4. Some women, for a like susceptibility, and less adaptability to the change 
and to out-door life than men. 

5. Valvular lesions, with rapid action of the heart, especially with the pre- 
vious exceptions. Diseases of the great vessels, such as aneurism. 

6. Marked and extensive emphysema, pneumothorax, and hydro-pneumothorax. 

7. Active pneumonia or existing haemoptysis. If the pneumonia or hemor- 
rhage is recent, the contra-indication amounts to little ; if remote, to nothing. If 
there is reason for some doubt, in any such otherwise favorable case, a gradual rise 
in elevation should be chosen. 

8. High bodily temperature, whether it be rather constant, as in some inflam- 
matory states, or in catarrhal extension beyond a tubercular zone, or whether it 
be regularly vacillating, as in a tubercular infection, i. e., daily low or subnormal 
in morning, and up to 103° or more later in the day, especially with suspicious 
laryngeal complication, or in so-called "catarrhal phthisis." 

9. Extensive involvement of lung tissue in diseased action, i. e., so that the 
healthy spirometrical record is more than one-half abridged. Of course advanced 
stage of disease renders this contra-indication much stronger. Dr. C. Theodore 
Williams, in his " Treatment of Pulmonary Consumption by Residence at High 
Altitudes," expresses this contra-indication as follows: " Phthisis with double cavi- 
ties, with or without pyrexia; cases of phthisis when the pulmonary area at low 
levels hardly suffices for respiratory purposes." 



SPECIFIC INFECTIOUS DISEASES. 



129 



10. The stage of softening, if accompanied by high daily fever, or in one of 
decided hemorrhagic diathesis. " Quick consumption," with or without intestinal 
ulceration or albuminuria. 

"Allowing patients to go to Colorado, which many physicians have 
done, as a dernier ressort, when they have not a five per cent chance 
of living six months anywhere, needs our strong condemnation. 

" It must always be remembered that every rule has its excep- 
tions, and that contra-indications may be neutralized by favorable 
circumstances, such as the best time of the year for the change, pre- 
vious experience of the individual in high climates, and the associa- 
tion of opposite conditions in the same patient. For instance, the 
writer has in mind an excitable lady with aortic insufficiency, neu- 
rasthenia, and some fibroid lung, who has done excellently well in 
Colorado. Another case of asthma and enlargement of the heart, 
with mitral regurgitation, was free from asthma while he remained, 
and was very little troubled with his valvular lesion." 

Dr. R. Thorne directs attention to the dwelling-house in relation 
to tuberculous consumption. He shows that no matter in what cli- 
mate or location the home is made, the character of the house and 
its environments is an important feature. 

Conditions of Dwelling-house tending to 

the Promotion of Tuberculous 

Consumption. 

1. A soil either (a) naturally damp and 
cold; or (b) subject to the influence 
of the rise and fall of a subsoil water 
lying within a few feet of the surface. 



2. A dwelling-house of which either the 
foundations, the area they enclose, or 
the walls, are, by reason of faulty 
construction or otherwise, liable to 
dampness. 

3. Such immediate surroundings of the 
dwelling-house as tend to prevent 
the free movement of air about it, 
and its ample exposure to the influ- 
ence of sunlight. 

4. Such structural defects as would pre- 
vent the maintenance within all parts 
of the dwelling-house of ample move- 
ment of air by day and by night, and 
free exposure of its habitable rooms 
to daylight. 



Conditions of Dwelling-house tending to 

the Prevention of Tuberculous 

Consumption. 

1. A soil which is (a) dry naturally; or 
(b) freed by artificial means from 
the injurious influence of dampness, 
and of the oscillations of the under- 
lying subsoil water. 

2. A dwelling-house so constructed as 
to be protected against dampness of 
site, foundations, and walls. 



Such open space on at least two op- 
posite sides of the dwelling-house as 
shall secure ample movement of air 
about it, together with its free expos- 
ure to the influence of sunlight. 

Such construction of dwelling-house 
as will secure for its habitable rooms 
and throughout its interior free move- 
ment of air by day and by night, and 
the free access of daylight. 



130 THE PRACTICE OF MEDICINE. 

The frequent occurrence of phthisis in numerous members of the 
same family living in the same house, and sometimes in individuals 
of different families occupying the same house, either together or in 
succession, strongly suggests the idea that the house rather than 
heredity is responsible, that it is the contagious virus in the house 
itself retaining its vitality for long periods (possibly aided by the 
transmission of an inherited tendency), which is really the cause of 
the disease. 

Now that we are beginning to believe in the specific nature of 
phthisis, we find that the evidence of contagion rapidly accumulates, 
and the necessity for disinfecting agencies of a thorough and pene- 
trating kind as applied to houses is becoming daily more apparent, 
inasmuch as " a house in which the disease has existed remains a 
centre of infection for an indefinite time." 

It is rather rashly advised by many authorities that the patient 
should live out-of-doors in all weather, and exercise as much as pos- 
sible. If this advice is not qualified it will lead to grave conse- 
quences. Undue and unnecessary exposure to rain, dampness, heat, 
etc., is injurious anywhere, and in all diseases. The patient should 
avoid these, but remain out-of-doors when the air is dry and warm 
or dry and cold, or even warm and moist, if the sun is shining ; being^ 
out in a warm rain is not injurious if the patient is clad in such a 
manner as to keep the whole body dry. As to exercise, I agree with 
the earnest advice of Dr. Karl von Ruck, of Ashville, N. C, whose 
large experience enables him to speak with authority. He has done 
good service in directing attention to the detrimental effects of over- 
exertion in pulmonary phthisis. "It is truly pitiful to see such 
patients literally drag themselves about, exhausting what little 
strength and recuperative power they still possess ; and more so yet 
to see how, under the mistaken association of exercise with the 
necessary out-door life, their wasting becomes more evident from 
day to day, their steps less secure, their frames more stooping, their 
stopping « to catch breath ' more frequent, and the hectic flush more 
distinct upon their sunken cheeks, until, finally, from utter exhaus- 
tion, or from resulting collapses and complications, they are obliged 
to keep to their house and room. But even here they resort to 
in-door gymnastics, swinging dumb bells or Indian clubs, or box 
against an imagined foe in the shape of a suspended and inflated rub- 



SPECIFIC INFECTIOUS DISEASES. 131 

ber air-bag or other contrivance calculated to offer resistence to their 
self-exhausting blows. Such sights are not uncommon in advanced 
cases, and the picture is only less painful in cases of the early stage, 
because there is still a relative appearance of well-being ; but, so 
long as they tax their strength to the utmost in violent exertions, 
the advanced stage is reached surely and steadily, although the pace 
may appear less rapid." 

The homeopathic treatment of phthisis, as I have before inti- 
mated, does not show any absolute curative results superior to that 
of the old school. If two patients of equal physical conditions were 
placed under the most approved treatment, one under the home- 
opathic, the other under the regular, with the same environment, I 
doubt if the result would be different. But here the comparison 
ends, for the palliative treatment of the homeopathic school is in- 
finitely superior. Painful and unpleasant symptoms are better 
palliated when treated according to the law of similia. In the last 
stage no treatment is equal to it in " smoothing the pathway to the 
grave." 

A wide and perhaps profitable field for speculation was opened 
by Dr. Mays when he published his views as to the nervous origin 
of phthisis. He contends that if we seek to prevent that disease, we 
must act through the nervous system, increasing its power, and con- 
sequently the nutrition of the organs diseased. Brown-Sequard, in 
a recent meeting of the Acadamie des Sciences, seems to adopt the 
same views. He announced that Dr. Arson val and himself had 
treated eighty-three tuberculous patients with injections of " tuber- 
cular fluid," filtered and sterilized ; of these, seventy-four were cured 
and only nine died. 

" Not only did the morbid reflexes, causes by the pulmonary irri- 
tation and determining the formation of the tuberculous neoplasm, 
disappear, but the improvement of the nutrition produced by the ac- 
tion of the medicament permitted the organism to become master over 
the morbid process." He claims that the bacilli are only " a secondary 
agent in tuberculosis," and that any treatment aimed directly against 
them is inefficacious. Dr. J. C. Burnett, in his monograph on "The 
Treatment of Consumption by the Attenuated Tuberculin," makes 
the same claims ; but he does not present the same proofs of cure as 
does Brown-Sequard. He only presents cases that were ameliorated, 



132 THE PRACTICE OF MEDICINE. 

or where the disease was apparently arrested. This is the theory 
which our school should adopt, instead of the absolute psora theory 
of Hahnemann. It may be that the metallic neurotic medicines, like 
gold, iron, zinc, manganese, or vegetable medicines which contain 
them, and, in addition, phosphorous, iodine, sulphur, and calcaria, 
will be found most appropriate. 

My own experience with phthisis does not encourage me to prom- 
ise a cure with medicines unless I can place the patients in a suit- 
able climate and environment. The medicines most likely to cure 
are arsenic, aurum, iodine, sanguinaria, enyodiction, eucalyptus, 
creosote, myrtol, morrhual, phosphorous, and a few others. The 
palliatives are all drugs which produce symptoms like those patients 
may have. 

Diet of Consumptives. — This must be divided into two methods : 
(1) The diet for prevention ; and (2) the diet for arrest. 

I have already given the prevention diet for tuberculous children, 
or those disposed to that condition. The diet of adults should not, 
much differ. The fats and oils can be given more freely for the 
prevention of phthisis, and in its incipient stage, than when the 
bacilli have actually invaded the tissues. Milk containing its proper 
amount of fat is an excellent food for some cases. There are patients 
who cannot take milk. For such I advise malted milk, with the 
addition of cream, and find it acceptable. Butter should be used 
freely on every kind of food, but it should not be heated sufficiently 
to injure it. Next to butter, the fat of bacon is best ; it is the most 
digestible and assimilable of all fats, and can be substituted for but- 
ter on all starchy foods. If the patient has a good digestion, bacon 
or pork and beans form an excellent food. The old fancy that pork 
caused scrofula or tuberculosis is obsolete. If the pork is tuberculous 
the process of thorough cooking destroys the bacilli, and none but 
barbarous nations eat raw pork. 

Among the recent studies on food appearing in " Merck's Bul- 
letin," September, 1892, is a very suggestive one relating to the 
improper use of fats in " seated " tuberculosis of the lungs. The 
writer, under the heading "The Vital Error in Oily Diet," says: 

" One great mistake that is commonly made in the therapeutic 
management of this class of cases, in which there is an inability to 
supply the full quotum of oxygen, is to recommend a free use of 



SPECIFIC INFECTIOUS DISEASES. 133 

oil, usually in the form of oleum morrhuse, either pure or in some 
mixture. Under the above described conditions, all forms of oils 
are objectionable, by virtue of the common physiological law that 
the fat first reaches the blood capillaries in the lungs. At this 
point the system takes in its new supply of oxygen, in consequence 
whereof the fat becomes so rapidly oxidized or transmuted that its 
identity is even lost in passing through the pulmonary circuit. 
Naturally used, a large amount of the oxygen taken in must be used 
up at the very point of its entrance into the system. A large amount 
of heat is generated in the lungs, which, to be of general service to 
the economy, must first be distributed through the circulating blood 
to all parts of the body, and thereby is often too rapidly dissipated 
before it can be fully utilized to aid in the proteid metabolism. The 
original in-taking capacity of the system for oxygen being already 
limited where there is a defective nutritive condition, this sudden 
and increased consumption of oxygen at its very point of entrance 
still further cuts down the amount of oxygen that can be distributed 
to the liver and other organs of the body. In consequence thereof 
there is quickly developed by the therapeutic measures instituted a 
still greater lack, throughout the system, of the oxygen which is 
required to perfectly transmute the proteid bodies absolutely needed 
for the nutritive work of the system ; and which might have been 
fully accomplished upon the buttermilk diet if the oil had been 
withheld, thereby avoiding this undue expenditure of oxygen in the 
pulmonary circuit. From the unquestionable fact that fat does 
not enter into the constructive metabolism of the body, but is rap- 
idly oxidized and transmuted into heat and energy in large amounts, 
it does of necessity stimulate and invigorate the whole system, and 
particularly the nervous mechanism, which responds quickly to this 
form of irritation. This naturally deludes, not only the poor suf- 
ferer, but the friends, and too often the physician, with the idea 
that the patient is rapidly and permanently gaining ; but, owing to 
the defective supply of oxygen to the system at large, proteid oxi- 
dation grows progressively less and less perfect, constructive meta- 
bolism grows weaker and weaker, until suddenly there is a rapid 
failure, and the descent toward the grave is so speedy that no human 
skill or earthly power can stay the downward progress. When the 
physiological powers have been sapped, both by the original disease 



134 THE PRACTICE OF MEDICINE. 

and by this false condition of oxidation, death becomes inevitable by 
this combined process of starvation and false stimulation." 

The same writer (like our Prof. R. N. Foster) is very favorable 
to a diet of buttermilk. After giving its composition, namely : water 
88 parts; proteid substances, 4.10 ; saccharine matter, 6.40 ; fat, .70; 
mineral salts, .80 ; he says : " Although a large portion of the fat has 
been removed, the remaining fluid, as compared with milk, has been 
concentrated so that the proteid elements and milk are increased." 
He advises the daily use of 102 ounces, which will give 4.19 ounces 
of proteid substance. " The decrease in fat, and the simultaneous 
rise in the percentage of milk-sugar, are two reasous why buttermilk 
is so valuable as a food-stuff." Of its value in pulmonary lesions 
he says : " Whenever there is a mechanical defect in the pulmonary 
organs, — as occurs in many diseases of the lungs, such as tuber- 
culosis, pleurisy with compression of the lung, emphysema, inter- 
stitial pneumonia so-called, syphilitic and other forms of sclerosis of 
the lungs, — the fact that this diet will yield so large a proportion of 
constructive and reparative material for the small outlay of oxygen 
used should always be remembered, and the patient be given the 
benefit of it. Clinically, this plan has long been followed in an em- 
pirical manner ; but, when the clinician is pressed for a logical and 
scientific explanation of the good results obtained, the common answer 
has been, ' the well-known clinical fact,' and probably that the but- 
termilk also possessed ' some special therapeutic properties,' while 
the true explanation lies in the simple physiological fact that more con- 
structive and reparative work can be developed, with the smallest 
expenditure of oxygen, when exclusively confined to a buttermilk diet, 
than upon any other form of food-stuff thus far computed." 

The " Salisbury diet," or all meat and hot water, is a singular 
" fad," and may be classed among the monomanias. This diet may 
be of great value in some disorders, as I am fully aware, but to 
recommend it as the diet in phthisis is so monstrous that it should 
not be considered for a moment. I have seen several of my patients 
whom I have made comfortable for years decline rapidly after 
adopting the diet. One of them died of uraemia, the direct result, 
I believe, of the exclusive use of meat. 

Alcohol has its sphere of beneficial action in phthisis, but that 
sphere is very limited. In large quantities, continued for a con- 



SPECIFIC INFECTIOUS DISEASES. 135 

siderable time, it acts like the improper and excessive use of fat, 
before mentioned. It should never be taken with cod-liver oil. I 
know this is counter to the usual practice, but I am sure my expe- 
rience has taught me its bad effects when given with oil. It may be 
taken with buttermilk, or milk not rich in fat. Only the purest 
wine or whisky should be used, and then in moderate quantities, not 
exceeding half an ounce or one ounce of alcohol per diem. Alcohol 
has no preventive or curative action in tuberculosis. Small quan- 
tities of pure spirits relieve the " sinking " and " depression " that 
comes from lack of food, when the patient cannot eat enough to sup- 
ply the demand. It should be taken after meals, never before. 



GONORRHOEA. 

Definition. — Of this disease I can say about the same that I said 
of syphilis : it is a unit, not an assemblage of diseases ; it is caused 
by a specific germ, the " gonococcus "; it may not cause the same 
symptoms in all persons, its manifestations varying with the suscep- 
tibilities and the constitution of the patient ; but all the time it is 
one disease only. 

Hahnemann must have had an inkling of the true nature of gon- 
orrhoea, for he calls the cause of the disease a " germ " (see his Les- 
ser Writings). He scouts the idea that there is any danger in 
arresting the discharge, for he says, " if we can arrest the discharge, 
we can do so only by destroying the germ/' How different is the 
teaching of some of his alleged followers of the present day ! I do 
not say that Hahnemann was correct in this assertion, for there seems 
to be proof that if the discharge is arrested by astringents the gono- 
cocci are driven into the circulation, and cause trouble in contig- 
uous and sometimes remote localities. I have seen orchitis and gon- 
orrhceal rheumatism follow the arrest of the urethral discharge by 
zinc; and I have seen ovaritis and salpingitis follow the use of 
astringent lotions to the vagina. I have also seen these local inflam- 
mations subside when the discharge from the urethra and vagina 
reappeared. Some authorities at the present day deny any such 
results, claiming that these local affections are due to the natural 
migrations of the gonococci, and would occur anyway. 



136 THE PRACTICE OF MEDICINE. 

Treatment. — No matter what medicine we use locally or intern- 
ally, it cannot cure the gonorrhoea unless it has the power of destroy- 
ing the gonococci. The most effectual medicines used internally 
are those which are capable of two effects : (1) they must be able 
to cause a similar irritation in the urinary passages over which they 
pass to get out of the body ; or (2) they must be able to kill the 
gonococci when brought in contact with them. Not all are able to 
do both. Cantharis can cause an inflammation of the urethra sim- 
ilar to the effects of the gonococcus, but it is not a destroyer of the 
gonococcus : for this reason it may and does reduce the urethritis, 
bat it cannot abolish the discharge ; and it is the same with several 
other useful medicines. 

Some years ago I suggested to a physician having a large prac- 
tice in venereal diseases that he make a trial of injections of copaiva 
in gonorrhoea. He reported several cases in which he had prescribed 
an aqua copaiva (one drop to one drachm), and stated that when the 
discharge was yellow, green, and profuse, it was soon cured. In gon- 
orrhoea! opthalmia this preparation when applied cured in a short 
time. The oils of cubebs, sandalwood, and gaultheria can be pre- 
pared and used in the same manner. This method, if thoroughly 
carried out, and proved to be successful, would supersede the internal 
administration of these unpleasant medicines. 

On the other hand, such medicines as copaiva, cubebs, sandal- 
wood, thuya, erigeron, ichthyol, mercury, and creosote, are capable 
of both effects ; yet none of these medicines of either class can cure 
a gonorrhoeal inflammation unless it passes over the mucous surfaces 
affected. They are of no use in orchitis, ovaritis, salpingitis, 
endometritis, or rheumatism of a gonorrhoeal origin. The reason is 
evident ; for in the beginning of the disease, before the cocci have 
penetrated deep into the mucous tissues of the urethra or vagina, or 
migrated to the interior of the uterus or fallopian tubes, the sper- 
matic ducts, or into the blood, injections into the urethra of a satu- 
rated solution of pyoctanin two per cent, nitrate of silver, corrosive 
sublimate 1 to 3000, thallin or ichthyol two per cent, creosote one 
per cent, or eucalyptol two per cent, will cure the disease by de- 
stroying the gonococci. Eecently, injections of peroxide of hydro- 
gen, five to ten volumes, is said to abort or arrest the disease if used 
the first twenty-four hours of the discharge. But the orchitis or 



SPECIFIC INFECTIOUS DISEASES. 137 

ovaritis will have to be treated by means of remedies having an affili- 
ation with these organs, namely, aconite, hamamelis, conium, Phyto- 
lacca, apis, salol, mercury, lilium, simulo, etc., and the rheumatism 
by means of aconite, bryonia, salicin, salicylate of soda (said to be 
almost specific), etc. 

Gonorrhoea in women is not now considered the mild disease it 
once was. Naeggerath and others have proved to us that the gonococ- 
cus may cause dangerous and long-lasting inflammation of the endo- 
metrium, fallopian tubes, and ovaries. We should not be content to 
use remedies confined to the vagina alone, but should apply them to 
the cervical canal and interior of the uterus, as soon as possible 
after the infection. If we wait too long we cannot avert serious 
consequences. 

In the above statements I refer only to genuine virulent gonor- 
rhoea ; there are several varieties of urethritis not caused by the 
gonococcus : 

(1) Catarrhal urethritis. Dr. Keyes says : "A priori, there is 
no reason why the influence of cold should not produce a catarrhal 
discharge from the mucous membrane of the urethra just as well as 
from the other mucous expansions, but clinical experience teaches us 
that this is the rarest of all causes "; yet I think I have seen a few 
cases occurring in delicate men, suffering from general catarrhal 
troubles. 

(2) Traumatic urethritis, caused by the use of instruments, the 
accidental entrance of foreign bodies, and the passage of gravel. I 
once treated a case of apparent virulent gonorrhoea in a man who 
denied positively having had intercourse for a year. After suffering 
two weeks, he discovered the end of a hair, identified as from the 
pubes, protruding from the urethra, after the extraction of which 
the discharge ceased of itself in a few days. Large crystals of uric 
acid in the urethra may cause a urethritis. 

(3) Infectious urethritis, from leucorrhoea, the lochia, or the 
menstrual flow. Keyes believes these may cause a " bastard gonor- 
rhoea," especially in men who have once had the genuine disease. 

The diagnostic test is the presence or absence of the virulent 
gonococcus. Keyes writes : " I have frequently examined the ure- 
thral discharges, and intensely purulent ones at that, and, failing to 
find the gonococcus, have pronounced the source of the alleged con- 



138 THE PRACTICE OF MEDICINE. 

tagion to be non-virulent, and the patient to possess a discharge 
which he could not communicate to another, and I have not yet been 
proved to be wrong." He admits that he has found gonoccoci in the 
discharge of men who did not communicate the disease to their 
wives, but it must be remembered that some persons possess a mys- 
terious immunity against this disease. 

Now it is in those varieties of urethritis not genuine that any 
one of the fifty or more medicines mentioned by Gouland and 
Lilienthal may prove the curative agent. 

Gleet is now known to be caused by two lesions of the urethra 
— stricture or patches of congestion, with or without granulations. 
Surgical treatment is needed for the former, but the latter may be 
cured by internal medicines. 



CHAPTER IV. 
CONSTITUTIONAL DISEASES. 



RHEUMATISM. 

Definition. — This term is applied to all inflammatory affections 
of the fibrous, muscular, and serous tissues which are not clearly 
referable to injury, gout, pyaemia, or any other well-recognized spe- 
cific diseases. When the joints are attacked it is called synovitis. 
It generally depends on some general or constitutional morbid state. 
The causes may be said to be : exposure to cold and wet, sudden 
chills, long-continued exposure to any cooling influence which exer- 
cise or clothing fails to counteract. Residence in cold, damp, and 
variable climates is a common cause. There is doubtless a heredi- 
tary predisposition to rheumatism in certain families. Women after 
child-birth and children after scarlet-fever are especially liable to it. 
One attack of rheumatism renders a person very susceptible to its 
recurrence. A residence in damp basements or houses, or the north 
side of hills, renders the occupant more liable to attacks. A joint 
or muscular tissue that has been sprained is more liable to be the 
locality of an attack. The joints which usually and chiefly suffer 
are the wrists, elbows, knees, and ankles ; and the muscles : the cer- 
vical, deltoid, and lumbar. 

Fever is usually present. The temperature, sometimes elevated 
only a degree or two, rarely rises above 105°. It is liable to daily 
variations, with usually a morning remission, but on the whole irreg- 
ular and untypical. There is no definite limit of duration to acute 
rheumatism. The patient may recover in a day or two, or in a week ; 
or the disease may continue several weeks ; or become chronic, with 
recurrences every few months, especially if the patient lives in the 
same damp, cold locality. The complications are too many and 
various to be mentioned in this work, but cardiac affections are the 



140 THE PRACTICE OF MEDICINE. 

most dangerous and important. The essential pathology of rheuma- 
tism is still an unsettled question. Bristowe says, " If there be a 
rheumatic poison, which is possible, its discovery is in the future." 
Fuller and Prout believe it is caused by the presence of lactic acid 
in the blood. A few writers believe it to be a neurosis ; others that 
it is infectious in its nature, and is caused by a specific bacillus. 
Professor Brouchard believes that the bacillus pyocyanicus is the spe- 
cific cause. He produced rheumatic phenomena in the lower ani- 
mals by the intravenous injection of this bacillus, and the toxines 
secreted by it. 

Treatment. — There is no disease, with the exception of phthisis, 
in which such a multiplicity of remedies have been used. From bleed- 
ing, calomel, and quinine, to alkalies, hydrotherapy, and " expect- 
ancy," all have been in turns tried and abandoned for something 
new. At present the dominant school seems to have settled down to 
the use of the salicylates and antipyretics, aided by hot fermenta- 
tions and wrapping with cotton. Although salicylic acid and the 
salicylates have been greatly abused, and have caused great injury 
to rheumatic patients when used in toxic doses, there is no possible 
doubt that they are of real benefit to rheumatism. How they act, 
and how they are able to cure this disease, cannot yet be explained. 
They are powerfully antiseptic, antifermentive, and antibacterial. 
Their favorable effects would almost lead one to believe in the 
theory of the microbic origin of rheumatism. They can in no sense 
cure by virtue of the law of similia, for in all the symptoms they 
cause there is not one that bears the slightest resemblance to those 
of rheumatism. 

Toxic doses of salicylic acid and its salts cause nearly all the 
phenomena of quinine poisoning. There is the same fulness of the 
head, roaring in the ears, headache, deafness, blindness, ptosis, 
strabismus, excessive sweating, collapse, cardiac failure, dyspnoea, 
restlessness passing into delirium-tremens, etc. The chief post- 
mortem changes are : breaking down of the blood, congestion of most 
of the viscera, ecchymoses on the skin and serous membranes, etc. 
Forty-eight grains have been followed by " vomiting, headache, total 
unconsciousness, stertorous breathing, and death in forty-eight 
hours." ("Virginia Medical Monthly," June, 1877.) Yet Dr. H. C. 
Wood ( u Therapeutics ") says, " Moderate doses increase the arte- 



CONSTITUTIONAL DISEASES. 141 

rial pressure and the frequency of the pulse ; it increases the force and 
energy of the heart's beat, probably by excitation of the vaso-motor 
centre." It seems that, like all other drugs, the action of moderate. 
and of toxic doses, is almost the opposite. Dr. TTood further says. 
•• Sphygmographic studies prove thzi the arterial pressure is usually 
elevated and never depressed by therapeutic doses of this drug." 
One would naturally ask. TThy not always give •• therapeutic " 
doses? also, What is the •• therapeutic " dose'/ The trouble with 
the dominant school is that they too often begin with the wrong 
dose. Instead of beainninsr with the safe and minute, thev orive the 
large and unsafe ones. They think they must get pathogenetic 
effects, in order to get the curative. In this respect the two schools 
differ widely. The "regulars" seek to attain the maximum dose 
that will cure with safety; the homeopaths seek the minimum dose 
that will cure, and is always safe. Text-books decide that the max- 
imum daily dose of the acid for adults is one drachm ; of salicylate 
of soda, ei^htv grains. Yet less than these amounts have caused 
dangerous symptoms and death. The dose is uncertain for two rea- 
sons : (1) There are some who are poisoned by small doses on 
account of idiosyncrasy. (2) It is cumulative in its action. Stick- 
ler's assertion has been verified abundantly, that when given in 
hourly doses of seven to fifteen grains "it causes a disappearance of 
the symptoms in less than forty-eight hours." These doses cannot 
always be given with safety. All authorities advise a close watch for- 
ks effects, and a cessation of its administration as soon as poisonous 
effects appear. To me this has always appeared criminal reckless- 
ness. There are many observers, myself among the number, who 
assert that thev can get good curative results bv means of doses of 
two or three grains every two or four hours, and if this quantity 
does not relieve in fortv-eight hours the drus: is not indicated. I 
have found that its curative action is greatly aided by the use of 
aconite in doses of one drop of the tincture or lx dilution every 
two hours. I refer to salicylate of soda. I never prescribe the acid, 
and I am imperative that only the natural (not synthetic) salicylate 
be dispensed. It has been demonstated that the artificial salicylic- 
acid contains a very poisonous constituent, which is not in the nat- 
ural, and some observers declare that this impurity is the agent that 
causes most of the toxic symptoms. 



142 THE PRACTICE OF MEDICINE. 

Dr. H. C. Wood (" Therapeutics ") says the most efficient methods 
of administering salicylic acid is in the form of oil of gaultheria and 
the salicylate of ammonia. He gives the formula for the latter : 
Salicylic acid, one drachm ; syrup, five drachms ; aqua ammonia, q. s. 
to dissolve the acid. Dose, a teaspoonful, which contains ten grains 
of the acid. The dose of oil of gaultheria is five to ten drops, in 
capsules or emulsion. I find our sugar discs or cones will hold one 
drop. I give two to four every two hours with good results. 

A reaction is setting in against the salicylates. Dr. McLagan, 
of the Royal Medical Society, London, in a recent discussion said he 
had seen deleterious results from the salicylate of soda and the other 
compounds, and that he had abandoned them. He now used salicin 
with better results. He asserted that while all the salicyl compounds 
were anti-rheumatic, salicin was the best. It gave rise to no unpleas- 
ant effects. He ordered thirty grains every hour for six hours, and 
found that in from twelve to twenty-four hours the pain and fever 
disappeared. The toxic action of salicin must be feeble, for Ranke 
is said to have taken three ounces without any notable effects. I am 
inclined to the opinion that the use of these drugs will be greatly 
modified or abandoned in a few years. The same laudatory praises 
were once heaped upon the iodides, quinine, salol, and antipyrin. It 
is certain that they are not safe in the large quantities heretofore 
given. 

The success of the homeopathic school in the treatment of rheu- 
matism is not brilliant, but we can boast that our treatment is not 
worse than the disease. Aconite seems to be our favorite remedy in 
the beginning of acute attacks. It certainly modifies the fever, 
relieves the pain and anxiety, and in some cases will limit the attack 
to a few days, in most cases when it is not hereditary or a dyscrasia. 
The regular school report good results from its use, and every day 
it improves in their estimation. I never saw any good effects from 
the dilutions above the 2x in rheumatic cases. 

Bryonia is next in popularity. Dr. Russell, of London, in his 
work on " Rheumatism," asserts that it is the most homeopathic rem- 
edy to that disease which we possess ; not only to the inflammation 
and pain, but even to the acid state of the blood, as witness the sour 
sweats. It is certainly the most efficient remedy in synovial and 
muscular rheumatism. I have often questioned if the bryonia indi- 



CONSTITUTIONAL DISEASES. 143 

genous to this country had similar medicinal powers, but no one 
seems to know. 

Francisca uniflora (manaca), a Brazilian remedy, has a reputa- 
tion as an anti-rheumatic in South America. From a study of its 
pathogenetic and curative effects, it seems to occupy a position between 
bryonia and cimicifuga. It causes " intense headache like a band 
around the head." This is as characteristic as the " band around the 
heart " of cactus. It causes great pain in the back of the head, neck, 
and spine, of a lancinating, stitching character ; a terrible aching all 
over, with great heat of the body, followed by profuse sweat, with 
subsidence of all the sufferings (from large doses of the decoction) . 
I found it quite useful in sub-acute cases, and when the rheumatism 
seemed to be connected with la grippe. In chronic cases it has acted 
well. The dose should be from five drops of the tincture or lx dilu- 
tion every two or four hours. 

Pulsatilla ought to be a good rheumatic remedy, as it belongs to 
the same botanical family as aconite, clematis, ranunculus, and cim- 
icifuga. The chief indication for its use is the flying character of 
the inflammation, going from one joint to another, the pale redness 
of the swelling, and the slight fever. If the rheumatism follows 
child-birth, suppressed menses, or a sudden disappearance of a 
catarrh, it is decidedly indicated. 

Cimicifuga has peculiar qualities, and its action in rheumatism is 
not fully understood. It is useful in a rheumatism with but slight 
fever, but great aching in the muscles and joints. The pain is out 
of proportion to the fever. It is especially useful in that variety of 
rheumatism which is associated with chorea. Ringer (" Thera- 
peutics," p. 443) says of it : " This remedy in my hands has yielded 
very satisfactory results in chronic rheumatism, — for instance, in 
rheumatoid arthrites, where the joints are much enlarged and stiff, 
— when the pains are worse at night." He finds it useful in con- 
ditions, such as I mentioned above, where Pulsatilla is useful. He 
says the "pains flit from place to place." He further instances 
cases when " the patient is troubled with pains, apparently rheumatic, 
in most of the joints, but with scarcely any fever or swelling. The dis- 
ease soon seats itself in one part, the wrist and hand ; the tissues here 
become much thickened, the bones of the wrists enlarged, till after 
a time all movement is lost ; warmth relieves the pain, which almost 



144 THE PRACTICE OF MEDICINE. 

ceases at night. Instant [?] relief will be given by this drug after 
iodide of potash and other remedies have been fairly tried in vain, 
the pain giving way at once, and the joints becoming supple and 
useful." 

Quinine or cinchona are rarely useful, but there is one condi- 
tion occurring in rheumatism where they are fully indicated : when 
the acute stage has passed, leaving the patient with swollen joints, 
an afternoon fever, and copious cold or hot sweats, night or day, as 
soon as he falls asleep. In such instances, ten to thirty drops of 
tincture cinchona, or one grain of quinine, every two hours, will 
soon dissipate these symptoms. In some cases of rheumatic night- 
sweats, quinine acts more promptly when it is given in solution 
in water, slightly acidulated with sulphuric acid. 

Rhus toxicodendron has a sphere of action peculiarly its own ; it 
affects the tendons around the joints, and the attachments of muscles 
(cimicifuga attacks the belly of the muscle). It is useful, not in 
inflammatory, but in sub-acute and chronic cases. The character- 
istic, so often quoted, " worse during rest, better by motion," is mis- 
understood by many. To be more definite, it is continued rest in one 
position, which causes a weary, aching, gnawing pain ; the patient is 
forced to move, but the attempt to move the affected part is attended 
with great pain on account of the soreness and stiffness ; but after 
a few moments of motion the pain is much better, and may continue 
better as long as he moves. This is the real condition which calls 
for rhus. 

Palliative and Auxiliary Treatment. — We cannot resist the 
entreaties of the patient to be relieved of pain, so that he can get 
some sleep and rest ; nor should we. It is cruel to allow the patient 
to be worn out by his sufferings. It retards the cure. External 
applications have always been, and always will be, demanded. It is 
doubtful if they really help much, but they give some relief, and 
divert the patient's mind. He thinks we are doing all we can. 
Compresses of hot water, or water rendered alkaline by nitrate, or 
acetate of potash, or bicarbonate of soda, sometimes seem to benefit. 
I never dared to use cold water, even if my patients would permit it. 
They seem to have an instinctive dread of any cold application. 
Embrocations, liniments, and ointments of all kinds have been used ; 
oil of sassafras, gaulthera, peppermint, and many others, have some 



CONSTITUTIONAL DISEASES. 145 

reputation. The common soap liniment, with a little menthol in it, 
is as good as any. 

Ichthyol has recently been highly praised. It is painted on the 
affected joint ; sufficient French chalk is strewn on to form a coat- 
ing, and the whole is to be covered with cotton. The application is 
to be renewed every twenty-four hours. (Lehman.) In a very severe 
case of articular rheumatism, Dr. Ackerman determined to try ich- 
thyol (one part ichthyol, four parts petroleum). First, the parts were 
bathed with soap and tepid water, and then the ointment was rubbed 
in ; after the first inunction the almost unbearable pain in the joints 
ceased and never returned, and the next morning the patient was 
able to walk about in her room ; the swelling gradually diminished, 
and in eight days she could walk several hours a day. Many such 
instances have recently been reported, and I verified its value in 
acute and chronic rheumatism of the joints. In chronic rheumatism 
it has been given internally (one grain in pill four times a day), 
with the result of lessening the swelling and stiffness. It is harm- 
less, and no unpleasant symptom need be feared. It combines in 
itself the virtues of iodine and sulphur. Many mineral oils are used, 
and kerosene has a great reputation among the people, who rub it 
freely into the joints. I have known it to benefit chronic, but never 
acute, cases. It will blister if used too freely. 

The nitrate and the acetate of potash are old remedies, and are 
still valued by physicians of all schools. The nitrate is indicated for 
about the same symptoms as colchicum in rheumatic gout, namely, 
after the pain subsides the joint swells more, but becomes softer ; 
the urine is scanty and high-colored, and deposits a sediment of red 
muddy matter. Ten grains in a wine-glass of water every four hours 
acts satisfactorily. The late Dr. Danforth valued very highly the 
acetate, and treated acute rheumatism successfully with doses of ten 
to twenty grains four times a day. The late Dr. Bird, of England, 
wrote : " I have seen the cure to be more rapid, the immediate relief 
more marked, by the use of acetate of potash, half an ounce, in 
divided doses, daring the twenty-four hours, largely diluted, than by 
any other treatment." Three days was the usual duration of the 
pain. He believed it lessened the chances of cardiac complications. 
The best anodyne for severe pain is McMunn's Elixir of Opium. 
Thirty to forty drops at night will give rest if not sleep. In very 



146 THE PRACTICE OF MEDICINE. 

bad cases a hypodermic of morphia with atropia will have to be 
used. Wrapping the joints in raw cotton and covering the whole 
with rubber cloth, causing the joints to sweat freely, generally gives 
relief. The diet should consist of milk mixed with Vichy water, 
equal parts, or with pure bicarbonate of soda in it, and other light 
foods suitable for fever. Lime juice and lemon juice are the only 
acids permitted, but water, especially alkaline, can be freely used as 
a beverage. 

Chronic rheumatism is a most perplexing and obstinate disease to 
treat, unless the physician has an establishment in which to place 
the patient, where baths, electricity, and massage can be used sys- 
tematically. The patient should be obliged to wear woolen next the 
skin all the year round ; eschew all alcoholic and malt liquors ; eat 
moderately of sugar and acids, but plenty of wholesome foods of 
which fat and lean meat form a good share. All hot springs, espe- 
cially if they are alkaline or contain sulphur, are very beneficial. 
The springs of French Lick, Blue Lick, White Sulphur, Red Sul- 
phur, and others in various states, should be resorted to, and the 
patient should remain long enough, often several months, to get the 
good effects of the water. In anaemic or impoverished cases the 
chalybeate waters should be used, together with cod-liver oil, ich- 
thyol, sulphur, and arsenic. 

It is of no use to give our most carefully chosen remedies unless 
they can be continued for weeks and months. If the rheumatism 
be syphilitic, iodide of potassa, in material but small doses, is neces- 
sary, and will act as a specific. Eclectic physicians value stillingia, 
corydalis, and berberis aquifolia in such cases. Phytolacca, root 
and berries, has been of service. The mud-baths of Europe and 
this country (Las Vegas, N. M.) have often effected surprising cures. 



ANAEMIA. 

Definition. — Anaemia may be defined as a reduction in the 
amount of blood as a whole, or of its corpuscles, or of its more 
important constituents, such as albumen and haemoglobin. It may 
be general or local. General anaemia, however, is the only form of 
which I shall treat. 



CONSTITUTIONAL DISEASES. 147 

Anaemia may be grouped as follows : (1) Primary or essential ; 
(2) secondary or symptomatic. 

PRIMARY ANEMIA. 

Primary anaemia is that condition known as chlorosis. It is 
chiefly met with in young girls, rarely seen in men. Blondes are 
more frequently affected than brunettes. It usually occurs between 
the fourteenth and seventeenth years. Its chief characteristic is a 
marked diminution of haemoglobin. The disease is most common 
among the ill-fed, overworked girls of large towns, who are con- 
fined all day in close, badly-lighted rooms. Lack of exercise and 
fresh air, and improper food, are the most important causes. It 
may, however, be caused by emotional and nervous disturbances. 
This fact has led many writers to consider chlorosis as a neurosis, 
which it probably often is. It is doubtless often caused by ptomaine 
poisoning, the result of constipation. 

Prognosis and Pathology. — Anaemia is rarely fatal. The fat 
of the body is generally retained. The heart is usually dilated and 
the left ventricle hypertrophied, but that organ resumes its normal 
condition when the blood becomes normal. The change in the 
haemoglobin is not a quantitative, but a qualitative change. The red 
corpuscles may show only a moderate grade of reduction, but the 
corpuscles themselves are very poor in haemoglobin. There may be 
all the physical symptoms and characteristics of a profound anaemia, 
with blood-corpuscles nearly at a normal standard. Chemical anal- 
ysis has shown that the normal percentage of iron in the haemoglobin 
is absent. 

Symptoms. — The complexion is peculiar. It has neither the 
blanched aspect of hemorrhage nor the muddy pallor of grave 
anaemia, but a yellow-green tinge, which has given rise to the com- 
mon name of " green sickness." But the cheeks may have a red- 
dish tint on exertion, and the lips may at times be red. The 
subjects complaiu of breathlessness and palpitation, and fainting-fits 
are common. The eyes have a peculiar brilliancy, and the sclerotica 
are of a sky-blue color. The appetite is capricious, and abnormal 
longings for acids, chalk, pencils, white paper, and clay are com- 
mon. Constipation is nearly always present. Dilation of the stom- 
ach is a frequent concomitant. 



148 THE PRACTICE OF MEDICINE. 

Palpitation and breathlessness may be the only distressing symp- 
toms of which the patient complains. Percussion may show a 
slight increase of dullness in the transverse diameter of the heart. 
A systolic murmur is heard at the apex or base On the right side 
of the neck, over the jugular vein, a continuous murmur may be 
heard — the " humming-top murmur." The pulse is usually full and 
soft. There is pulsation in the peripheral veins. Fever is not uncom- 
mon, and the patients suffer from headache, neuralgia, hysteria, dys- 
menorrhea or amenorrhea. Chlorosis may be mistaken for phthisis, 
Bright's disease, heart-disease, or leukemia. If any great doubt 
exists, the blood should be examined chemically and microscopically. 



SECONDARY ANAEMIA. 

Secondary anaemia may be caused by : (1) hemorrhage ; (2) 
albumenuria or suppuration ; (3) cancer ; (4) inanition, from defec- 
tive assimilation of food ; (5) toxic, from poisoning by lead, mer- 
cury, arsenic, copper, quinine, malaria, syphilis, snake-bites, and 
various organic poisons ; (6) parasites in the stomach and intes- 
tines ; (7) pregnancy and parturition ; and finally, (8) pernicious 
anaemia. 

None of the above secondary varieties need any particular descrip- 
tion, except pernicious anaemia. This may be caused by influences 
which have not yet been ascertained. There is sometimes a history 
of gastro-intestinal disturbances, mental shock, or worry. 

Symptoms. — Addison gives the following graphic description of 
this disease : "It makes its approach in so slow and insidious a man- 
ner that the patient can hardly fix a date to the earliest feeling of 
that languor which is shortly to become so extreme. The counte- 
nance gets pale ; the white of the eyes becomes pearly ; the general 
frame flabby rather than wasted ; the pulse becomes large, but 
remarkably soft and compressible, and occasionally with a slight 
jerk, especially under the slightest excitement ; there is an increas- 
ing indisposition to exertion, with an uncomfortable feeling of f aint- 
ness or breathlessness in attempting it ; the heart is readily made to 
palpitate ; the whole surface or the body presents a blanched and 
waxy appearance ; the lips, gums, and tongue seem bloodless ; the 
flabbiness of the solids increases ; the appetite fails ; extreme Ian- 



CONSTITUTIONAL DISEASES. 149 

guor and faintness supervene ; breathlessness and palpitations are 
produced by the most trifling exertion or emotion ; some slight oedema 
is probably perceived about the ankles ; the debility becomes ex- 
treme ; the patient can no longer rise from bed ; the mind occa- 
sionally wanders ; he falls into a prostrate and half-torpid state, and 
at length expires. Nevertheless to the very last, and after a sickness 
of several months' duration, the bulkiness of the general frame and 
the amount of obesity often presents a most striking contrast to the 
failure and exhaustion observable in every other respect." 

The condition of blood is best given by Osier in his recent " Prac- 
tice of Medicine ": 

" The corpuscles may sink to one-fifth or less of the normal num- 
ber. They may sink to 500,000 per cubic millimetre, and in a case 
of Quincke's the number was reduced to 143,000 per cubic milli- 
metre. The haemoglobin is relatively increased, so that the individ- 
ual globular richness is plus a condition exactly opposite to that 
which occurs in chlorosis, in which the corpuscular richness in color- 
ing matter is minus. The relative increase in the haemoglobin is 
probably associated with the average increase in the size of the red 
blood-corpuscles. Microscopically the red blood-corpuscles present a 
great variation in size, and there can be seen large forms, megalo- 
cytes, which are often ovid in form, measuring eight, eleven, or even 
fifteen micromillimetres in diameter, a circumstance Henry regards 
as indicating a reversion to a lower type. Laache thinks these path- 
ognomic, and they certainly form a constant feature. There are 
also small round cells, microcytes, from two to six micromillimetres 
in diameter, and of a deep red color. The corpuscles show a remark- 
able irregularity in form, elongated and rodlike, or pyriform ; one 
end of a corpuscle may retain its shape, while the other is narrow and 
extended. To this condition of irregularity Quincke gave the name 
poikilocytosis. The leucocytes are generally diminished in number, 
and the relative percentage of the mononuclear elements is somewhat 
higher than in normal blood." 

The cardio-vascular symptoms are important. Haemic murmurs 
are constantly present. The larger arteries pulsate visibly, and the 
throbbing in them may be distressing to the patient. The pulse is 
full, and frequently suggests the water-hammer beat of aortic insuf- 
ficiency. The capillary pulse is frequently to be seen. The super- 



150 THE PRACTICE OF MEDICINE. 

ficial veins are often prominent, and in two cases I have seen well- 
marked pulsation in them. Hemorrhages may occur, either in the 
skin or from the mucous surfaces. Retinal hemorrhages are com- 
mon. There are rarely any bad symptoms in the respiratory organs. 

Gastro-intestinal symptoms, such as dyspepsia, nausea, and vom- 
iting, may be present throughout the disease. Diarrhoea is not 
infrequent. The urine is usually of a low specific gravity, and 
sometimes pale, but in other instances it is of a deep sherry color, 
shown by Hunter and Mott to be due to great excess of urobilin. 
Fever is a variable symptom. For weeks at a time the temperature 
may be normal, and then irregular pyrexia may develop. Nervous 
symptoms may occur, numbness and tingling, and occasionally symp- 
toms resembling those of tabes. Lepine reports a case of extensive 
paralysis. 

Diagnosis. — The close observer will have no difficulty in dis- 
tinguishing this disease from chlorosis. The relative condition of 
the blood is the chief diagnostic sign. 

Prognosis in pernicious anaemia is bad. Osier says that under 
the arsenical treatment the ratio of recovery is greater than under 
any other treatment. Bramwell was the first to introduce this treat- 
ment into the old school. He gives what seems enormous doses, 
but it matters not — if it cures. It may be that the function of 
assimilation is so paralyzed that only a minute quantity of all that 
is given is absorbed by the organism. He gives Fowler's solution 
in constantly increasing doses. Beginning with three drops after 
meals, it is increased to five at the end of the first week, ten at the 
end of the second week, fifteen at the end of the third week, and if 
necessary increased to twenty to twenty-five drops. He says these 
large doses are well borne. Many cases are reported cured. Dr. 
A. McPherson, of Toronto ("Medical Record," 1890), presented 
to the Canadian Medical Association five interesting cases, in which 
there was irregular elevation of temperature; pallor, with " lemon 
tint," but without emaciation ; high-colored urine with low specific 
gravity, with the characteristic blood changes, and gastro-intestinal 
disturbances. In one case the blood contained 745,000 red corpus- 
cles per cubic millimetre, instead of the normal 5,000,000, the char- 
acters of the corpuscles being those typical of the disease. This 
excessive blood destruction, commencing in the portal system and due 



CONSTITUTIONAL DISEASES. 151 

to some poison absorbed from the intestinal tract, in which there is 
probably greatly increased putrefaction going on, was the great char- 
acteristic of the disease. In the treatment of these cases he urged 
the importance of keeping the bowels, as far as possible, clear of 
decomposing matter, and believed, in addition to an occasional mild 
calomel purge, that the use of an intestinal disinfectant, such as 
beta-napthol, five grains, or thymol, three grains, three times a day, 
would prove beneficial. In the list of medicines arsenic stands at 
the head and should be given in small doses, say one-fortieth of a 
grain, every two or three hours after food. If not well borne, smaller 
doses, even a half drop of Fowler's solution, should be tried every 
hour. The benefit of arsenic was probably by its action on the blood, 
rendering the haemoglobin more difficult of being dissolved out of 
the corpuscles. The diet should be highly nutritious, and consist of 
iron-bearing food, as yolk of egg, milk, meat, and cereals of all kinds. 
It is advisable to treat all grave persistent anaemias with arsenic, 
as by so doing we might possibly prevent some cases of pernicious 
anaemia. 

Arsenious acid 2x in one-grain doses sometimes acts better than 
Fowler's solution. Yalengin's solution often acts better than Fow- 
ler's. Rest in bed and nutritious diet are necessary. Iron has no 
good effect in this form. Picric acid ought to have a curative effect 
in minute doses, as it is homeopathically indicated by the character- 
istic condition of the blood, and symptoms. In some cases the picrate 
of zinc may be particularly indicated. 

Arndt particularly recommends calc. phos., but gives no illus- 
trative cases to prove its value. 

The Differential Diagnosis of Anaemia. — True anaemia signi- 
fies a reduction in the quantity of blood. It occurs in an acute man- 
ner after hemorrhages, or it may be chronic as a manifestation of 
emaciation of the organism. Quantitative anaemia is characterized by 
pallor, although the latter symptom may be present even when the 
blood is qualitatively and quantitatively normal. This latter condi- 
tion is present in syncope, where the patient has not lost a drop of 
blood, but bleeds, says Dr. Neusser, " in his own abdomen," the 
cutaneous vessels being contracted and the intestinal dilated. In 
collapse, an anaemia similar to that of syncope is present. The for- 
mer are considered by Neusser as prototypes of acute pseudo- 



152 THE PRACTICE OF MEDICINE. 

anaemia, and are to be differentiated from chronic pseudo-anaemia, 
which originates in an irregular distribution of the blood, as in 
exophthalmic goitre and the so-called nervous anaemia attended by 
violent pulsation of the aorta. A form of true anaemia, attended 
with qualitative changes of the blood, is chlorosis. Chlorosis is 
characterized by diminution of the coloring matter of the blood, the 
red corpuscles not being diminished in number. The pronounced 
anaemia of the mucous membranes and the skin and the fugacious 
oedema are not pathognomonic of chlorosis, being also present in 
post-hemorrhagic anaemia. Dyspeptic chlorosis is referred to as 
anaemia accompanied by gastric disturbances, the latter being symp- 
tomatically most prominent. Gastric disturbances are nearly always 
present in chlorosis, and are characterized either by chemical or 
mechanical functional disturbances of the stomach. 

The chemical disturbances result in either increased or dimin- 
ished acidity of the gastric secretion, the latter prevailing. In some 
cases hydrochloric acid may be entirely absent. This latter condi- 
tion is also present in atrophy of the gastric glands, pernicious 
anaemia, and carcinoma of the stomach, thus making the differential 
diagnosis often difficult. In carcinoma of the stomach, the contents 
nearly always show an acid reaction due to the presence of lactic 
acid, notwithstanding the absence of hydrochloric acid, and the 
quantity of pepsin is diminished. In the dyspeptic forms of chlor- 
osis, on the contrary, notwithstanding the absence of hydrochloric 
acid, pepsin and peptones are always present. 

Eegarding treatment, Neusser says that many cases are cured by 
simple iron treatment, whereas in others not only is the iron badly 
tolerated, but it intensifies the gastric disturbances. The intolerance 
of many forms of dyspeptic chlorosis for iron may be removed by 
previous inhalations of oxygen, of which large quantities must be 
used. He begins with fifty quarts daily, and quickly increases this 
to from one hundred to two hundred quarts. Crude and desiccated 
blood have been employed in the treatment, and although he has 
used them, they were discontinued in consequence of diarrhoea being 
developed. From many sources it has been observed that in patients 
with chlorosis, who could not tolerate any preparation of iron, the 
ingestion of large quantities of raw meat was attended with suc- 
cessful results. This latter method seems in no wise irrational, as 



CONSTITUTIONAL DISEASES. 153 

when raw meat is consumed iron is introduced in the form of haemo- 
globin, which is at once taken up by the circulation. The objections 
to it are the obnoxiousness of raw meat to many patients and the 
danger of taenia. Aside from the objection already cited, the meat 
diet is often contra-indicated in those cases attended by foetor from 
the mouth. The odor is largely derived from scatal, a ptomaine 
derived from animal food, and for this reason an absolutely vegetable 
diet is indicated. 

There are a few meat extracts, of which Valentine's is the type, 
that are much better than raw meats or blood. These meat extracts 
are made as follows : The blood and juices are expressed by intense 
pressure, at a temperature of 40° F. Then these juices are heated 
in vacuo, at a temperature of 170° F., which does not injure the albu- 
min or haemoglobin. I have used Valentine's, Libby's, and Wyeth's, 
and I find them highly nutritious and palatable to all patients, who 
soon tire of raw meat or its expressed juice, even with the addition 
of acid muriatic. All other beef extracts that I have tested are lit- 
tle better than stimulants, acting only by their salts. An eminent 
English medical writer on Dietetics declares that beef tea and beef 
extracts are of no more food value than urine, which they closely 
resemble. This is because the fibrin, albumen, and haemoglobin are 
destroyed by the intense heat to which the meat juices are subjected. 
The three preparations I mentioned can be given in cold water, cold 
milk, Vichy water, or Apollinaris — from thirty to sixty drops every 
two or four hours. 

The Treatment of Anaemia. — In the treatment of anaemia, the 
indicatio causalis should be predominant. If the cause be hemor- 
rhages, these should be stopped by internal and external remedies, 
by compression, by ice, etc. If profuse discharges (as prolonged 
suppuration) be the cause, such constitutional and local measures 
should be resorted to as will diminish or arrest them. Under this 
head come cold abscesses, bronchorrhcea, cystitis with copious muco- 
purulent exudation, and chronic diarrhoea. Excessive lactation and 
excessive venery act in a similar way. While these inordinate 
wastes are going on, the blood is being despoiled of its richest ele- 
ments, its corpuscles and its plasmatic albuminates, and any treat- 
ment to be efficacious must reduce to a minimum these losses. If 
the cause be syphilis, tuberculosis, or cancer, the casual indication is 



154 THE PRACTICE OF MEDICINE. 

sufficiently plain. The victim of venereal diseases may get rid of 
his anaemia, and regain a fair measure of health and vigor, under 
the reconstituent and anti-syphilitic influence of mercury and potas- 
sium iodide ; the tuberculous patient may improve by an out-door 
life and a fortifying regimen generally ; even the subject of cancer 
may be, for a time at least, benefitted by medical or surgical means 
directed to his morbid conditions. The anaemia may be of toxic ori- 
gin, being due to malaria, to poisoning by lead, by phosphorus, by 
mercury, etc., and the treatment will be addressed to such of these 
agencies as may be found to be operative in the particular case. It 
would take up too much space here to enumerate all the causes of 
anaemia and follow out the indications. 

In iodiopathic anaemia, one of the most fruitful causes is insuffi- 
cient food ; then want of light and air, excessive bodily exercise, 
intense heat or cold, depressing emotions, are all important etiolog- 
ical agencies, and, when once recognized, will suggest the only suc- 
cessful means of cure. Anaemia, moreover, besides being symptom- 
atic of hemorrhages, profuse discharges, severe cachexiae (as before 
mentioned), may arise from obstacles to taking food (as in stricture 
of the oesophagus), to dyspepsia, to organic diseases of the heart, to 
chronic pulmonary disease, to fever, and finally to diseases of the 
blood-making organs (lymphatic glands, spleen, and marrow of the 
bones) . Anaemia originating in any of these ways can be successfully 
met only by attention to etiological therapeutics. One of the most 
common forms of anaemia is that which is symptomatic of severe and 
prolonged dyspepsia, whether atonic or functional, or the result of 
chronic catarrh, dilatation of the stomach, round ulcer, etc., and the 
means, dietetic and remedial, must be directed to the restoration of 
the damaged digestive functions. 

The anaemia of heart-disease is, of course, curable or incurable, 
according to the nature of the cardiac affection to which it belongs. 
Digitalis, strophanthus, nitroglycerine, caffeine, adonidine, more than 
iron or arsenic, are indicated in this anaemia. In the absence of any yet 
definitely known pathological lesions causative of chlorosis or perni- 
cious anaemia (although the theory which assigns both maladies to dis- 
ease of the haematopoietic organs appears to be the most plausable), it 
is impossible as yet to fulfil the inclicatio causalis, and we must con- 
tent ourselves with attending to the indicatio morbi. In fact, in all 



CONSTITUTIONAL DISEASES. 155 

kinds of anaemia this indication imposes itself upon the practitioner. 
To promote sanguification in all forms of anaemia, we rely on two 
orders of remedial agents : medicinal and hygienic. To take up, 
first, the medicinal means (though these are by no means the most 
important), there is still no medicine of such general utility as iron. 
It is true that we are still ignorant of the precise way in which iron 
does good, but the fact is none the less indisputable that in a multi- 
tude of cases under the influence of this agent the blood improves in 
corpuscular richness, and all the nutritive energies are augmented. 
The ferruginous preparations are legion, and we believe, with Nie- 
meyer, that special indications for the exhibition of one or the other 
of them cannot yet be laid down. In simple anaemia and in chlor- 
osis, almost any of the iron preparations are well tolerated, but in 
special cases it is necessary to select that kind which agrees best with 
the stomach. The citrate, tartrate, lactate, pyrophosphate, the 
reduced iron, Blaud's pill, and the chloro-peptonate are all mild prep- 
arations, and are generally borne by weak and delicate stomachs. The 
tincture of the chloride (the most-used of all the liquid preparations) 
sometimes acts with marvellous promptness and efficacy, but many 
patients cannot take it, and not every pharmaceutical product is reli- 
able. Where iron alone does not agree, it may sometimes be asso- 
ciated to advantage with other medicines. Thus the combination 
with aloes or aloin is especially valuable in many cases of anaemia or 
chlorosis with constipation. 

A favorite pill contains dried sulphate of iron and extract of 
aloes, of each one grain. To this is sometimes added for each pill 
one-quarter of a grain of mix vomica, a little capsicum, or one- 
thirtieth of a grain of arsenic. Dr. Julius Pollock urges the addi- 
tion of a little rhubarb to the dose of iron in disordered states of the 
stomach. A pill much prescribed by Vulpian in anaemia and 
chlorosis (" Clinique Medicate" p. 470) consisted of iron by 
hydrogen, soft extract of cinchona, pulverized rhei, of each equal 
parts ; this was called the compound iron pill of Charite Hospital. 
The late Dr. Gueneau de Mussy (" Clinique Medicale" t. i. p. 
209), whose success as a practitioner is well known, was fond of a 
combination of bismuth with iron, and where the latter, despite the 
addition of bismuth, still produced irritation of the digestive organs, 
he did not hesitate to add a little opiuui or belladonna. This writer 



156 THE PRACTICE OF MEDICINE. 

urges that it is not by furnishing to the blood an element that is 
wanting that iron does good, but by stimulating nutrition, and points 
to the fact that etiolated plants become green by watering them 
with ferruginous preparations, and at the same time their chloro- 
phyll does not contain any iron. Huguenin, of Paris, was one of 
the first to propose the hypodermic method of administering iron, 
especially in pernicious anaemia, where iron, when taken into the 
stomach, is not assimilated ; and Dr. J. M. DaCosta, of Philadel- 
phia, has used the dialyzed iron to advantage in this way. From 
five to thirty drops daily may be injected under the skin without 
fear of abscess. 

Dr. Laache, of Christiania, declared, during a recent discussion, 
that the sole indication for the administration of iron was the exist- 
ence of true primary chlorosis. The continued employment of prepar- 
ations of iron is not advisable, and yet relapses are very common as 
soon as the use of this drug is discontinued. It is very possible that 
the vascular changes noted by Virchow may have much to do with 
the occurrence of these frequent relapses. 

Arsenic gives good results in cases of progressive pernicious 
anaemia, but here, too, relapses are not uncommon. It is also neces- 
sary, before passing final judgment on the value of any remedy 
in this disease, to remember that spontaneous recoveries sometimes 
take place. For this reason it is always well to be guarded in the 
prognosis of a case of anaemia, even though it be of extreme sever- 
ity and accompanied by frequent fainting spells. The mode of action 
of arsenic is as little understood as is that of iron. We know, how- 
ever, that in the case in which iron is useful (chlorosis), the haemo- 
globin is reduced in amount both relatively and absolutely, that is to 
say, the globules are reduced in number and are also pale in color. 
In cases of pernicious anaemia, however, in which iron is of no ser- 
vice, the haemoglobin is only reduced in so far as the number of 
red blood-corpuscles is less, the corpuscles themselves being of nor- 
mal color, and containing the correct proportion of this principle. 
It would seem, therefore, that the iron acts in a special manner 
upon the haemoglobin. In certain cases, the so-called foecal anaemia 
purgatives are of undoubted service. This form of the disease is 
probably due to a chronic poisoning by the foecal matter remain- 
ing in the intestines. Kreosote, in doses of one or two drops 



CONSTITUTIONAL DISEASES. 157 

after meals, has been found curative in this form of chloro-anaemia. 

As to the utility of inhalations of oxygen, authorities are not at 
all agreed. In pernicious anaemia, or in that form which remains 
after exhausting hemorrhages, transfusion is often of real service. 

Arsenic has of late been highly extolled as a remedy in anaemia, 
especially in pernicious anaemia, and is said by excellent clinical 
authorities to merit a place next to iron ; in fact, in many cases it 
does good where the iron preparations utterly fail. Drs. Byrom 
Bramwell, Mackenzie, and Lockie, of England, have advocated the 
more free use of arsenical preparations for a tonic and haematinic 
effect. The latter, in the " British Medical Journal " (December 
7, 1878), affirms that in many cases of anaemia approaching the 
so-called essential or pernicious anaemia, arsenic will confer more 
benefit than any other remedy. Dr. William Osier, in the " Boston 
Medical and Surgical Journal " (Yol. CXXIX., p. 454), reports 
remarkable results in puerperal anaemia from the continued admin- 
istration of Fowler's solution ; he reviews the history of the employ- 
ment of arsenic in pernicious anaemia, and calls attention to the fact 
that we do not fully understand the reason why this drug should be 
so useful in some cases and so useless in others. (If Osier had 
selected arsenic in his cases, according to the law of similia, he would 
not find so many failures.) It certainly has often the effect in pro- 
found anaemia much resembling that of a specific, like that of quinine 
in ague for instance. " The initial dose," he says, " should be five 
drops, gradually increased to twenty or thirty drops, three times a 
day. Pufnness of the eyelids, oedema above the eyebrows, vomiting 
or diarrhoea, indicate that the drug should be suspended for a time. 
The point of greatest importance is that this remedy should be given 
a long time and in increasing doses." I do not advise the large 
doses of Osier, nor do I believe it should cause drug symptoms. At 
the same time I know that above the 3x arsenic is useless in anaemia. 

Other remedies, as phosphorus, manganese, cod-liver oil, malt 
preparations, and alcohol, find their application in certain cases. 
Cod-liver oil is more readily oxidizable than any other fat, and, 
when tolerated, often constitutes a powerful auxiliary to other means 
of treatment. Alcohol, in the form of wine or ale, and sometimes 
where there is great debility, and especially in that anaemia which 
attends febrile diseases, in the form of brandy or whisky, frequently 



158 THE PRACTICE OF MEDICINE. 

proves of aid in stimulating the functions of digestion and assimila- 
tion, and preventing inordinate waste. But the hygienic treatment, 
which comprehends dietetics, exercise, hydrotherapy, serotherapy, 
and climatotherapy, attention to rest, the restoration of normal 
habits of sleep, the rigorous avoidance of all excesses, of all injurious 
excitements, of depressing emotions, etc., is of far more importance 
than the medicinal treatment. Hydrotherapy is a powerful stimu- 
lant of nutrition, and is commended by Fleury, Dujardin-Beaumetz, 
Becqueril, and others, as one of the most active agents in the treat- 
ment of anaemia. The douches should be as cold as can well be 
borne, and should be very short at the commencement, of not more 
than five or six seconds duration. The utility of out-door exercise, 
of sojourn in the country or at the sea-side, and of mountain life, is 
sufficiently obvious as being among nature's best and most certain 
means of reinvigoration. The effect of rarified air upon the body 
has been studied by different observers. M. Paul Bert found that 
the blood of the llama of South America absorbed on an average 
twenty-five per cent more oxygen than the blood of the herbivora of 
the plains. Muntz kept some rabbits upon the Pic du Midi for a 
year, after which time he found their blood much richer in the 
haemoglobin than that of the rabbits kept for comparison on the 
lowlands. In order to prove that it was the rarified air and not 
other conditions which produced this change, Regnard, in his labor- 
atory, subjected a rabbit, enclosed under a bell-glass, to a continuous 
atmospheric depression, two bell-glasses being placed together so as 
to allow the rabbit to pass from one to the other when it became 
necessary to clean and disinfect his quarters. After living in an 
atmospheric depression corresponding to the height of 3000 metres, 
which is that of the great St. Bernard, the rabbit was taken out. 
He was a little fatter than when he had been put in. It was found 
that his blood absorbed 25 c. c. of oxygen for every 100 c. c. of 
blood; while in the control-rabbits kept under normal conditions, 
it was only 17 c. c. These experiments suggest an explanation of 
the benefit often derived by anaemic and chlorotic patients by going 
to the mountainous districts. Many cases of anaemia and chlorosis 
are due primarily to sedentary habits, to breathing hot or impure 
air, and to neglect of exercise. Without an entire change in the 
habits of living (due rest, sleep, and abandonment of every degrad- 



CONSTITUTIONAL DISEASES. 159 

ing, depressing passion being observed), the dietetic treatment of 
anaemia can do little good. The dietetic treatment is, of course, the 
most essential, for it is only through the assimilation of food that 
we can hope for restoration. On this subject we must be very brief. 
As a general rule, food for the anaemic should be abundant, nutri- 
tious, and easily digestible. There should be predominance of album- 
inates (milk, eggs, meats, and fish) over carbo-hydrates. Some 
patients will do better on light meals given frequently ; others on 
not more than two meals a day. For patients with feeble digestive 
powers, beef peptones, underdone meats, and even, for a time, pan- 
creatized milk, may be necessary. Some bad cases of anaemia and 
chlorosis do remarkably well on a dietetic system by stuffing, like 
that recommended by Dr. S. Weir Mitchell in his little treatise on 
" Fat and Blood.'' This is combined with much passive exercise by 
massage and electricity. Gavage, or forced feeding, performed by 
the oesophageal tube, gives often brilliant results in certain anaemic 
conditions where it is impossible sufficiently to nourish the patient 
by mouth, but where food of a proper kind, when introduced into 
the stomach, is well digested and assimilated. Some of the most 
discouraging cases are those that are attended with absolute repug- 
nance to all food, as is often witnessed in pernicious anaemia. Med- 
icines do little towards restoring appetite and digestion, and unless 
the physician can obtain hints from etiology, and enforce the proper 
hygiene, he is powerless to benefit his patient. 

There are other drugs which are as valuable as those above men- 
tioned. I value nux vomica, ignatia, and strychnia as highly as iron, 
when the causes lie in the digestive organs, from anaemia of the 
spinal cord, or from depressing mental influences. A combination 
of active principles often act better than if given in alternation. 
Among these I would name arseniates of iron, strychnia and gold; 
the citrate of iron and strychnia ; digitalis and strychnia ; the hypo- 
phosphites of lime and soda, with arsenic or strychnia. 

Summary of the treatment of the different forms of anaemia : 
Chlorosis. — Iron in some form is the chief specific. I have found 
in my practice that the syrup of nitrogenized iron, digitalis, and wild 
cherry, which I introduced many years ago, has given better satis- 
faction than any other medicine. It is particularly indicated in the 
cardio-vascular disturbances of chlorosis ; dose, one teaspoonful three 



160 THE PRACTICE OF MEDICINE. 

times a day. Next to this I value the compound pill I also intro- 
duced, composed of iron one-eighth grain, digitalis one-fifth grain, 
and strychnia one-hundredth grain ; dose, one pill after meals. In 
some cases of chlorosis there is an abnormal arterial tension, fainting- 
fits are common, and the fingers are cold and seem absolutely blood- 
less. In such cases, if one-hundredth grain of glonoin is added to each 
dose of the above medicines, the patient will improve faster, and be 
free from the faintings. There is great value in the natural ferru- 
ginous waters, especially when the iron is associated with the alka- 
line salts and sulphur. It is often advisable to send anaemic patients 
to the springs, if they are located in high altitudes, or where there is 
no malaria and the sanitary conditions are good. There are many 
chalybeate springs in Virginia, North Carolina, New York, Colo- 
rado, and California, where the surroundings are all that can be 
desired. Levigo water, brought from a spring in Tyrol, containing 
arseniate of iron, has been of great service to me in many obstinate 
cases. The dose is one or two teaspoonfuls after meals. It acts 
best when taken in a glass of Vichy or some similar alkaline water, 
or some pure spring or distilled water. Its action can be aided by 
phosphorus, phosphoric acid, ignatia, strychnia, helonias, manganese, 
and a residence in the pure rarified air of a high altitude. 

Pernicious Anaemia. — Arsenic is the principal remedy ; picric 
acid, picrate of zinc, and lachesis may be of value* in some cases. 

I desire here to protest against the popular notion that chlorotic 
patients should exercise in the open air. They may walk slowly or 
sit or ride ; but if they exercise to the point of dyspnoea or palpita- 
tion, the heart will suffer, and take on pathological changes, and the 
strength of the patient will be wasted. 

Anaemia from emotional causes are best treated by change of sur- 
roundings and by phosphoric acid, ignatia, helonias, aurum, and med- 
icines selected to meet special symptoms. I have cured two cases of 
profound anaemia from disappointed love, with phosphoric acid, five 
drops of the dilute three times a day ; many cases caused by grief 
with ignatia 3x ; several cases when there was disturbance of the 
reproductive organs, with helonias and cimicifuga. 

Anaemia from hemorrhages require ergotin 2x, ustilago lx, hydras- 
tis 2x, cinchona mother tincture, and phosphoric acid, even after the 
loss of blood has been arrested. They prevent its recurrence. Beef 



CONSTITUTIONAL DISEASES. 161 

juices, eggs, dark meats, and open-air life are imperatively neces- 
sary, if the patient is strong enough to go out. 

Anaemia from cancer may be improved but not cured by pier ate 
of iron, arseniate of iron, and the hvpophosphites. 

Anaemia from syphilis is cured by mercury, especially by the 
iodides, and by iodide of potassa and iodide of iron. 

When the anaemia is from drug-poisoning, as from quinine, lead, 
arsenic, or mercury, their chemical antidotes must be given. 

One important rule should be followed in treating anaemia, 
namely, the drug selected for the essential condition should be con- 
tinued for weeks and months. Meanwhile collateral symptoms 
should be met by appropriate remedies given temporarily. 

A novel method of treating chlorosis has been adopted by Dr. J. 
Cheron in "The Lancet," 1892, namely: scarification of the os 
uteri. Shubert and others recommend it. The amount of blood to be 
drawn is about one gramme to every kilogramme of body weight. 
According to the above observers these slight bleedings greatly 
increase the number of red corpuscles and the amount of haemoglobin 
in the blood. Dr. Cheron, in making use of scarification of the os in 
the treatment of old standing disease in chlorotic patients, found 
that the general health as well as the local conditions improved. In 
many cases an analysis of the blood during and after treatment 
showed continuous improvement after each scarification. In chlo- 
rotic patients congestions of the womb is habitual, and it is easy to 
obtain forty to sixty grammes of blood at one operation. This local 
treatment seems likely to be of great benefit to chlorotic women, ano! 
it is easy to understand that it can be performed much more read- 
ily than venesection. The scarification, if done with antiseptic pre- 
cautions, is not accompanied by risk. 

Dr. Lowenthal, in the " Revue d' Obstetrique et de Gynecologic," 
reports the results of treating twenty-three patients suffering from 
chlorosis or hysteria by suppressing the menses. The method em- 
ployed consisted in injections of hot water of the temperature of 
at least 49° C, with complete rest in bed. In some very rare cases 
iced water was employed preferably to hot water. In eighteen cases 
the remedy was employed for pure chlorosis. The five others com- 
prised two cases of grave hysteria, and three of convalescence from 

exhausting maladies. In these latter the convalescence was short- 

ii 



162 THE PRACTICE OF MEDICINE. 

ened. One of the hysterical patients received a marked advantage, 
and all the chlorotics were cured with surprising rapidity, and with- 
out ulterior medication, after from three to five menstrual suppres- 
sions. No unpleasant consequences were noted. One pint of water 
is advised three times daily. 

In advising this treatment, we shall find decided opposition from 
the people, because it runs counter to the popular belief of the dan- 
ger of arresting the menstrual flow. The same prejudice is against 
arresting it when the flow exceeds its normal time in cases of menor- 
rhagia, by injections of hot water. I am decidedly in favor of the 
practice, for I have tested it in both disorders, nor have I ever seen 
any unpleasant results follow the practice. Patients with metror- 
rhagia and menorrhagia have all improved under this method of 
treatment. It is rational to presume that if we prevent the loss of 
blood, improvement must follow. 



CORPULENCY. 

Definition. — This condition of abnormal nutrition is also called 
polysarcia and obesity. In some cases obesity can hardly be said to 
be abnormal, as when it is hereditary in families, and when the sub- 
jects live to a good old age and observe no bad effects from it, except 
their great bulk. It generally appears after middle age, and often 
in persons who when young were remarkable for their slender pro- 
portions. This is particularly the case among the Jews and some 
oriental nations. Corpulency is not uncommon in young children, 
and I have seen a few cases in infancy where it amounted to mon- 
strous proportions. 

A peculiarity of obesity which I have never seen mentioned by 
any writer is, that it sometimes selects certain portions of the body 
in preference to others. The face and neck may be fat, and no 
other portion. In some women the bust is selected, and the mammae 
grow to monstrous size. In one case which came under my observa- 
tion, the mammae, if they could have been weighed, would have 
turned the scales at ten pounds each. The trunk alone is some- 
times adipose, while the arms and legs are slender. The abdomen, 
in both sexes, is the seat of adipose deposit after middle life. The 



CONSTITUTIONAL DISEASES. 163 

thighs and hips in some women increase in size out of proportion to 
the lower portion of the leg. In such cases the perverted nutrition 
is not equally distributed, — why, we do not yet know. 

The causes are undoubtedly, in most cases, over-eating and over- 
drinking of fluids, even plain water. But there are exceptions to 
this, for among my most adipose patients I have noted many who 
ate very little, and drank less. I particularly remember an Irish 
girl who lived in my family, and I am sure that she did not con- 
sume more than two ounces of solid food a day, yet her weight con- 
stantly increased. Lack of proper exercise is a potent cause of 
obesity. The drinking of whisky and beer are among the most 
common causes. 

Murchison puts corpulency among the functional disorders of the 
liver — as one of the consequences of hepatic derangement ; and he 
also places emaciation or " abnormal elimination," among its con- 
sequences. 

The belief, so long prevalent, that fatty food causes corpulency 
is now abandoned. Murchison admits this, and says that a diet of 
starch is much more conducive to obesity. He says, " Some of the 
fattest persons I have met were females who had for a long time 
eaten little or no fat or oily matter, and who have taken very little 
solid food, but who have contracted the habit of drinking fre- 
quently some mixture of alcohol and sugar, beer, champagne and 
other wines, and who at the same time have taken little exercise and 
have suffered from deranged liver." 

I am sure that the excessive drinking of calcareous water is a cause 
of obesity. The so-called " Schwenniger cure," to which Prince Bis- 
marck was subjected, consisted mainly of Ebstein's treatment, with the 
prohibition of nearly all fluids. Ebstein's theory of the causes of corpu- 
lency accords with those of the best physiologists. He says it is not 
caused by fats, but by all starchy and saccharine foods. In treating 
of the causes, he writes : " But this much is settled, that to avoid corpu- 
lency, or to remove it after it sets in, we must do exactly opposite 
from what we do to achieve it. Before we begin to speak of the 
treatment of corpulency, we have to examine the question : What 
food has a tendency to the accumulation of fat ? The first question 
to be settled is, whether the fat which people deposit in their body is 
acquired, or manufactured in the body. . . . There can be no doubt 



164 THE PRACTICE OF MEDICINE. 

about one principle, i. e., that every species of animals has its own 
specific fat, — the mutton always as mutton-fat, a dog never contains 
ox-fat. But it is next to be examined whether they gather it from 
what they eat, or whether they manufacture it from hydro-carbons, 
or from the albuminates which they eat. We know, however, that 
not all fat is derived from the absorbed food, because cows, for 
example, furnish more fat in the milk they yield than they take in 
with their food. They must, therefore, manufacture this surplus of 
fat, either out of the albuminates or the hydro-carbons which their 
food contains. But whether any of the fat which we eat, in a nor- 
mal and a healthy body, is retained and collects as fat is not 
yet decided, because, for example, carnivorous, i. e., such animals 
as hardly eat any other food than meat and fat, accumulate very lit- 
tle fat, and this is shown very clearly by the dogs. The butcher's 
dog, which eats hardly anything but meat and fat, seldom fattens. 
But the lap-dog, which eats very little meat, and a great many dainty 
bits, especially sugar (hydro-carbon), fattens very quickly ; which 
fact, however, is partially to be explained by the idle life he leads. 
On the other side, it is certain beyond doubt that albuminates create 
fat. Some authorities claim that one hundred per cent albumen 
may create fifty-one to fifty-two per cent fat. But we also know 
to-day that Liebig was mistaken when he thought that hydro-car- 
bons (sugar, starch, and their products, like alcohol) participate in 
the creation of fat. But while they do not directly take any part 
in it, they help indirectly. When there is a large provision of 
albuminates (meat, milk, eggs, flour, beans, etc.), the hydro-carbons, 
like sugar, alcohol, etc., increase the deposit of fat out of the albu- 
men. The reason for this is that they contain a large amount of 
oxygen, and are thereby decomposed in the body into water and car- 
bonates, and in so doing protect a part of the albumen against com- 
plete destruction. Fat, on the contrary, decomposes very slowly 
into water and carbonates, and therefore does not favor the deposit 
of fat out of the albuminates (like meat), because such albuminates, 
with much supply of fat, decompose completely, without leaving any 
■fat behind. Thus, we understand why fat is such a very important 
and valuable food. A great authority of the present time on the 
physiology of nutrition, the German Professor Voit, of the Uni- 
versity of Leipzig, demands as necessary wholesome food for a work- 



CONSTITUTIONAL DISEASES. 165 

ingman fifteen ounces of starch (flour, bread, etc.), four ounces of 
meat food, and two ounces of fat. Nay, lie even prefers about ten 
ounces of bread only and eight ounces of fat. The advantage of fat 
for the performance of his work is twofold : (1) It diminishes the 
decomposition of albuminates, and therefore retains their faculty of 
supporting strength and increasing the power of the muscle ; (2) 
it decreases corpulency, as we have shown above, and thereby again 
increases his working power." 

" To the poor laboring man, as well as to all who have to per- 
form hard labor and endure much fatigue (such as seamen, soldiers, 
etc.), fat proves itself to be of inestimable value. The same is true 
of beasts of burden. The great quantity of fat which camels, after 
having been well fed at home, accumulate in their humps enables 
them to stand the hardships of the desert so easily. They live, on 
these travels, where they are imperfectly fed, from the superabund- 
ance of their humps, without suffering much thereby. The chamois- 
hunters on their hard wanderings take fat only along, and no meat 
of any kind, and they surely could not stand their fatigue if they 
were fattened by it. And we saw an official recognition of the value 
of fat (in spite of Banting's prohibition) when the Emperor of Ger- 
many demanded fifteen ounces of fat as daily food for his soldiers, 
before they entered France in the famous war of 1870. 

" We have this demonstrated so far : (1) The dangers which 
threaten corpulent people, and thereby the necessity of working 
against corpulency with all means at our disposal ; (2) the fact that 
corpulency does not usually exist or originate without too much 
food ; (3) that a certain arrangement of nutrition favors develop- 
ment of corpulency, especially albuminates and too many hydro- 
carbons, while fat, if eaten in proper proportion, does not increase 
fat." (Murchison on Diseases of the Liver.) 

Writing of the treatment, he denounces the " Banting treatment " 
as simply " starvation treatment, leading to inanition, and useless 
and dangerous." The Banting treatment, like that of Catani the 
Italian, consists of eating lean meat only, except a little very dry 
toast, and as little water as possible, excluding all fats, oils, butter, 
milk, cream, potatoes, bread, etc. Oertel's treatment was the same, 
to which he added systematic exercise, principally hill or mountain 
climbing. 



166 THE PRACTICE OF MEDICINE. 

Ebstein's treatment consists of the following rules : " Sugar, 
sweet things of any kind, potatoes in every form, must be avoided. 
The quantity of bread must be reduced to not more than six or seven 
ounces, daily, and the vegetables allowed are : asparagus, spinach, 
cabbage, and especially the legumes, like beans and peas. Of meat 
every kind may be eaten, and fat more especially. The fat of ham, 
pork, or lamb is not only harmless but useful, as also kidney-fat or 
bone-marrow. The sauces or ' gravy ' must be fat, and vegetables 
ought to be prepared with a great deal of butter." 

He says : "It will require a special prudence to watch a corpu- 
lent patient when he begins, under treatment, to lose weight and 
diminish his bulk. This must, by all means, proceed very slowly, 
and the patient must feel comparatively well, free from pains, espe- 
cial weakness, or any other disagreeable symptoms. The diet must 
consist of three meals : breakfast, with coffee or tea, — but this with- 
out milk and sugar, — dinner, and supper." 

" The dinner is the most important meal. Nothing should be taken 
between breakfast and dinner. Supper must be comparatively light. 
With dinner the patient may take one or two glasses of light wine, 
white or red. Beer is to be avoided, unless the hydro-carbons are 
proportionately reduced, and then only a very small quantity can be 
allowed. The following example may serve as a good illustration of 
this diet, and the accompanying bill-of-fare as an excellent regimen 
for such patients. The case was that of an otherwise healthy man 
of forty-four years, who had suffered from his twenty-fifth year from 
corpulency, which had constantly increased, while up to that time he 
had always been lean. His habits of life were moderate, he drank 
very little, but his occupation was a quiet, sitting one, and his diet 
was full of albumen, of little fat, and a great deal of hydro-carbons, 
sugar, etc. Under this diet and mode of life he grew constantly fatter. 
Then he began to take advice and followed our regimen, with the re- 
sult of losing twenty pounds in three-quarters of a year. At the same 
time his capacity for physical and mental work, which had decreased 
considerably during his constantly increasing corpulency, began to 
increase again, and his general feeling was one of comfort and health. 
He had abstained especially from all fat while he grew corpulent." 

His diet afterwards, according to the system above described, was 
the following : 



CONSTITUTIONAL DISEASES. 167 

(1) Breakfast. One large cup of black tea, without milk and 
sugar ; about two ounces of white or brown bread, and plenty of but- 
ter. Time: in summer, 6.30 ; in winter, 7.30 a. m. 

(2) Dinner (about 2 p. M.). Soup (with bone-marrow occa- 
sionally), four to six ounces of meat, boiled or roasted, with fat gravy, 
especially fat meat, plenty of vegetables, cabbage, and, most of all, 
legumes (peas and beans). Beets, carrots, and turnips were, on ac- 
count of the sugar they contained, almost totally excluded, potatoes 
entirely. After dinner, a little fresh fruit ; occasionally some salad 
or stewed fruit, but without sugar. To this was added two or three 
glasses of light wine. Soon after dinner a large cup of black tea, 
again without sugar or milk. 

(3) Supper (between 7 and 8 p. m.). In winter regularly, and 
in summer occasionally, another large cup of tea, without any sugar 
or milk. One egg, or some small plate of fat meat, or both ; or 
some ham with its fat, sausage, smoked or fresh fish, two ounces of 
white bread, with plenty of butter, and occasionally a little cheese, 
and a little fresh fruit. 

" Nobody will assert that this is a bill-of-f are of which anyone need 
complain, either in quantity or variety, and to live on such a regi- 
men for the whole life is certainly no great hardship. This man 
never suffered from dyspepsia ; his appetite was always good ; there 
was always a yearning for his dinner, a distinctly-felt, keen appe- 
tite. For supper the desire was not so great, and the appetite was 
easily appeased. The mode of life during this time was generally a 
very quiet one, of even activity, physical exercise moderate, and 
rarely ever were there any great walking-trips undertaken. And 
this is the treatment, diet, and mode of life to be recommended gen- 
erally to the corpulent patient, — of course always to be influenced 
by individual appearance and feeling, — and this should be under the 
direction of a physician, as we said before and cannot repeat too 
often. The same identical treatment proves itself highly useful in 
that form of corpulency which is, as is so often the case, the result 
of anaemia." 

" We refer here to the history of one case out of many at our dis- 
posal, as illustrating best the results of our treatment. A young 
lady of about thirty years suffered from a constantly increasing cor- 
pulency, accompanied by anaemia of a high degree, a feeling of great 



168 THE PRACTICE OF MEDICINE. 

weakness, and very scanty courses. All this developed itself while 
the lady followed a very unsuitable dietetic regimen. Iron was used 
without any benefit ; but on adopting the diet above described the 
circumference of the waist decreased about three inches and every- 
thing else in proportion. In half a year the fat had nearly disap- 
peared, and at the same time the other troubles decreased, the courses 
became regular in every way, and all symptoms of anaemia vanished. 

" The same good results are observed in cases of corpulency com- 
plicated with gout, and also where the appearance indicates an affec- 
tion of the heart. Furthermore, we may add that this same treat- 
ment has proved itself extremely beneficial in that other plague of 
mankind, i. e., diabetes. Meat and fat alone has often cured this 
horrible disease, where all other treatments have failed. In con- 
clusion, we beg to repeat that we hope to have proved that the idea 
that fat makes fat is a prejudice; and I may add that physio- 
logical experiments and experiences agree fully in this respect with 
the result of medical practice. If the latter had proved nothing but 
that fat people do not get fatter by eating fat, it should be suf- 
ficient to remove forever the 'fat prejudice.' But we have seen, 
on the contrary, that fat in proper proportion with albuminates and 
hydrates of carbon actually reduces corpulency." 

Dr. Yeo, after a full consideration of the various methods, gives 
the following useful summary : 

" The albuminates in the form of animal food should be strictly 
limited. Farinaceous and all starchy foods should be reduced to a 
minimum. Sugar should be entirely prohibited. A moderate 
amount of fats, for the reasons given by Ebstein, should be allowed. 
Only a small quantity of fluid should be permitted at meals, but 
enough should be allowed to aid in the solution and digestion of the 
food. Hot water or warm aromatic beverages may be taken freely 
between meals or at the end of the digestive process, especially in 
gouty cases, on account of their eliminative action. No beer, porter, 
or sweet wines of any kind should be taken ; no spirits, except in 
very small quantity. It should be generally recognized that the use 
of alcohol is one of the most common provocatives of obesity. A 
little hock, still Moselle, or light claret, with some alkaline table 
water is all that should be allowed. The beneficial effects of such 
diet will be aided by abundant exercise on foot and by the free use 



CONSTITUTIONAL DISEASES. 169 

of saline purgatives, so that we may insure a complete daily unload- 
ing of the intestinal canal. It is only necessary to mention a few- 
other details. Of animal foods, all kinds of lean meat may be 
taken, poultry, game, fish (eels, salmon, and mackerel are best 
avoided), and eggs. 

" Meat should not be taken more than once a day, and not more 
than six ounces of cooked meat at a time. Two lightly boiled or 
poached eggs may be taken at one other meal, or a little grilled fish. 
Bread should be toasted in thin slices and completely, not browned 
on the surface merely. Hard captain's-biscuit may also be taken. 
Soups should be avoided, except a few tablespoonfuls of clear soup. 
Milk should be avoided, unless skimmed and taken as the chief 
article of diet. All milk and farinaceous puddings and pastry of all 
kinds are forbidden. Fresh vegetables and fruit are permitted. 

" It is important to bear in mind that the actual quantity of food 
permitted must have a due relation to the physical development of 
the individual, and what would be adequate in one case might be 
altogether inadequate in the case of another person of larger phy- 
sique." 

Medicinal Treatment. — The medicinal treatment of obesity is 
neither safe nor satisfactory. The basis of nearly all anti-fat prepa- 
rations is iodine. This drug, when given in pathogenetic doses for a 
considerable time, will cause emaciation. Under its influence the 
fatty deposits first disappear, then the glandular structures atrophy, 
the mammae, ovaries, testicles, and liver dwindle and cease to per- 
form their functions. Neither the iodides of potash, soda, ammonia, 
or lime, nor the bromides should be used for this purpose. 

Fucus vesiculosus, a species of sea-weed, which contains a large 
percentage of iodine, bromine, and salines, has long had a reputa- 
tion for the removal of obesity. It was used by the people for that 
purpose long before it was introduced into medicine. A decoction, 
as strong as could be taken without disturbing digestion, was given 
three times a day. It is now prepared in both fluid and solid 
extract. The dose of the former is one to four fluid drachms ; of 
the latter, five to thirty grains three times a day. M. Duchesne- 
Dupare claims that it has the effect of " diminishing fat, without in 
other respects injuring the health." In the " Pharmacology of the 
Newer Remedies" (pp. 106-113), many cases are reported of cor- 



170 THE PRACTICE OF MEDICINE. 

pulency, often excessive, safely removed by this drug. All the 
reporters agree, however, that a modification of Ebstein's diet should 
be maintained during its use. 

" This remedy is best taken in the morning, fasting. Its use 
requires no change in the ordinary diet. I have always allowed per- 
sons to eat according to their desire ; and, apart from too much 
farinaceous food, beer, prolonged baths, and a too sedentary life, 
which it is always necessary to avoid, I never impose serious priva- 
tions. The action of the fucus on the system is very easily proved. 
After using it some time the patient feels lighter and more active ; 
the stomach acts with more rapidity, and the hour of repast is more 
impatiently looked for. Flatulency diminishes and then disappears 
with those who have been habitually accustomed to it. The act of 
digestion is no longer accompanied by flushings of the face, by full- 
ness and weight in the epigastric region, and flashes of heat toward 
the head. 

"It is not until after two or three weeks that we begin to observe 
special and characteristic phenomena ; then the urine of those under 
its influence becomes generally more abundant, and begins to present 
on its surface a coating or black film. It is from this period that 
the resolvent properties are manifested, and the first intimation of 
becoming thinner are displayed. This result, which some look for- 
ward to with much impatience, is every day more decided, and, 
although variable in degree, has never yet failed. 

" These different phenomena show us, then, in the fucus vesicu- 
losa a real stimulant of the absorbent system, concentrating its 
action principally on the fatty globules. The thinness which it 
determines is not always produced in a uniform manner. I have 
seen it limited to certain isolated parts, which are then almost always 
those where the fatty tissues accumulate in the greatest abundance. 
Thus, with one it is the chest, with another the abdomen, and with the 
third the nape of the neck and the upper part of the shoulders. 

" But the destruction of fatty matter is not all that the resolving 
properties of the fucus vesiculosus is capable of accomplishing ; for 
many observations seem to prove that the same properties may become 
useful in certain other diseases, such as cutaneous infiltration, passive 
dropsy, atonic gout, etc." 

I have prescribed it in all its forms, but my experience has not 



CONSTITUTIONAL DISEASES. 171 

been favorable to its use. It has assisted the proper diet, but it can 
no more be used to excess than iodine. The waters of the springs 
of Marienbad, Carlsbad, and others in this country, like the French 
Lick Springs in Indiana and the sulpho-saline springs in Florida, 
Colorado, and other states, will, if used freely, assist in the removal 
of corpulency. It is my opinion that they do not act like iodine on 
the absorbents, but by provoking excessive excretion, and by prevent- 
ing the perfect digestion and assimilation of food. In most instances 
laxative or purgative doses are given an hour or less after meals, 
which has the effect of hurrying the food out of the stomach and 
along the intestinal tract. In treating obesity, constipation must not 
be allowed to exist, and those laxative waters which contain the most 
sulphates of soda should be selected, and a sufficient quantity pre- 
scribed to move the bowels gently but completely. 

In the first edition of " New Remedies " I called attention to the 
observation that birds which fed on the berries of phytolacca lost 
their adipose tissue. I suggested that this effect was probably due to 
the large percentage of potash contained in all parts of the plant, and 
also to some specific power possessed by phytolacca which resembled 
the effects of iodine. In a few cases I used the juice of the berries 
as an anti-fat, but the result was not decisive. Lately an inspissated 
juice of the berries has been widely advertised, and a few physicians 
have reported good results from its use ; but there is not yet sufficient 
testimony to warrant me in recommending it unreservedly. 

Vinegar has been very successful in carrying off the fat, but the 
patient has usually been carried off with it. 



MAL-NUTEITION.— EMACIATION.— LEANNESS. 

Thinness is often a family trait, and it may be a national one. 
Some tribes of half-civilized people appear as possessing abnormal 
thinness, just as other tribes are adipose. When it is hereditary 
but little can be done to bring about plumpness. If a member of a 
plump family becomes thin, we are justified in considering the case 
one of mal-nutrition. The individual may eat and drink more than 
any other member of the family, yet remain at less than his normal 
weight, or lose it continuously. In the absence of tuberculosis or 
wasting discharges, we must diagnose the case as one of mal-assim- 



172 THE PR A CTICE OF MEDICINE. 

ilation. There are many causes of this condition which do not show 
themselves in any other way. Murchison suggests that " in conse- 
quence of a deficient formation of bile, or of its impeded passage 
into the bowels, the assimilation of fatty and albuminous matter is 
interfered with." Diseases of the pancreas which prevent the normal 
secretion of pancreatin have the same result, especially in relation 
to the assimilation and digestion of fat. Such persons have an 
instinctive aversion to fatty foods. Disorder of the glycogenic func- 
tion of the liver may lead to emaciation. Most persons of a nervous 
temperament seem impelled by a desire to be constantly in motion ; 
even in sleep the body is not quiet. The mental processes in such 
persons are abnormally active. How often we have children under 
our care whose attendants complain that they " cannot keep them 
still a minute." This condition is almost a disease — an abnormal 
motility — and leads to excessive thinness of body. Many women 
suffer in the same way ; they waste faster than they gain. Such 
persons are in danger of ultimately becoming the victims of chorea, 
paralysis, insanity, or neurasthenia. They cannot be cured by diet. 
They should be deprived of all external stimuli — light, noise, inter- 
course with the outside world, in fact, such isolation as Weir Mitchell 
advises. In this isolation, together with massage and over-feeding, 
the leanest becomes plump in a few months, and their nervous 
erethism leaves them. 

Rest, mental and physical, even under unfavorable conditions in 
life, favors corpulency. When animals are to be fattened rapidly 
they are placed in dark stables, or cells, and no loud noises are 
allowed near them. It is said that men who do light work in the 
cellars of a brewery get fat, but if they are removed to the upper 
rooms they become lean. Some oriental nations look upon excessive 
corpulency in women as the acme of physical beauty. Consequently 
when girls reach a marriageable age, about their tenth year, they are 
confined in dark rooms and fed on a sweet food made of flour, and 
allowed sweetmeats, but deprived of water. In a few months these 
girls become " veritable lumps of fat," as unsightly to Europeans as 
they are fascinating to the Turks. In some parts of Africa women 
fatten themselves on fresh honey and fresh dates. In Europe the 
excessive use of champagne and nuts by indolent women soon brings 
on corpulency. 






CONSTITUTIONAL DISEASES. 173 

It is evident that the dietetic treatment of thinness must be the 
opposite of that of corpulency. We must first ascertain if the func- 
tions of the liver are duly performed. If not, they should be 
aroused by small doses of hepatic medicines. The two most efficient 
are iridin and euonymin. The stools should be examined to see if 
they contain bile, and if the food taken is digested completely. If 
the liver is not at fault, pepsin, pancreatin, papoid, or diastase, should 
be given. The vegetable oils seem to me to aid the formation of fat 
better than any animal fat, except cod-liver oil. It is doubtful if 
cod-oil owes its fattening properties to the oil itself, for if its con- 
stituents are separated from the oil — forming a solid substance 
called morrhuol — and given to a person suffering from mal-nutrition, 
we see the same effects as from the oil. This substance contains 
iodine, bromine, calcarea, and phosphorus, all of which in small 
quantities aid in arresting emaciation. 1 have seen excellent results 
from one grain of morrhuol given after each meal. 

If the functional activity of the stomach is normal, those who 
are thin should be allowed or obliged to eat all sweet farinaceous 
fruits, and foods sweetened with sugar or honey, keeping just out- 
side the bounds of indigestion. Advise against all active exercise, 
or as much indolence as is compatible with health. The oil extracted 
from the berries of saw-palmetto appears to possess extraordinary 
fattening properties. The " razor-back " hogs of Florida and the 
Gulf States suddenly get almost fat during the season when they 
can find the fruit of this shrub. It is a greenish oil, partly vola- 
tile, of a pungent taste, but can be given in maltine, or rubbed up 
with sugar. The dose is fifteen to thirty drops three times a day. 
I have known it to increase the weight to a surprising degree in a 
few months. The tincture of the berries is a stimulant and irritant 
to the genito-urinary and glandular system when taken in large 
doses, and should not be used except in atonic diseases of those tis- 
sues. Only the pure oil should be used when an increase of weight 
only is desired. 

When a lean and emaciated person cannot take fat into the stom- 
ach, it can be applied by the dermatic method. Fat rubbed into the 
clean skin is absorbed and assimilated by the body. It has been 
observed that the skin of the emaciated is generally dry and harsh. 
This condition calls for the local use of fats. I recall many cases of 



174 THE PRACTICE OF MEDICINE. 

children and adults whose weight was increased by this method. 
The fats most readily absorbed by the skin are lard, butter, cocoa- 
nut oil, olive oil, purified cod-liver oil, and oil of saw-palmetto. 

Dr. T. C. Duncan, in his interesting little treatise entitled " How 
to Be Plump," gives many practical directions. On page 45 he 
writes : 

"Oil or fat may be given by the skin, i. e., applied topically if 
the digestive organs will not take it. E. g., in one case child teeth- 
ing ; marasmatic with whooping cough ; had been running down for 
months, in spite of the most skillful treatment and abundant tonics. 
When I took charge of the case I thought it could not live two weeks 
unless speedily relieved. No diet that I could suggest would be 
taken. Medicines had little effect. Ordered it rubbed every night 
with sweet-oil. In three days it began to eat, and in two weeks it 
ate the whole time. ' Soup, soup,' was its cry all day, and if awake 
at night it would call for ' soup.' From a living skeleton, with a 
dry, sallow, dirty skin, it became plump, fair, rosy — the picture of 
health." 



DIABETES MELLITUS. 

Definition. — A disease of the nutritive system, in which sugar 
accumulates in the blood, and is excreted in the urine. The daily 
quantity of urine is also greatly increased. 

Purdy, whose monograph is one of the best in medical literature, 
says, " We have reason to believe that diabetes was known in periods 
of remote antiquity." He quotes from the Ayur Veda, from Hip- 
pocrates, Celsus, Galen, and Aretoeus, who gave brief but graphic 
descriptions of the disease. But the peculiarity of the urine, its 
sweet properties, was not observed, until about two hundred years 
ago. It was, however, about one hundred years ago that Dobson 
showed that this sweet principle was sugar, which he demonstrated 
by evaporating the urine and producing the sugar in crystals. 

This disease is believed by many to be hereditary. The fact 
that it often coexists in husband and wife has prompted a few 
writers to suggest that it may be contagious. It is generally a dis- 
ease of adult life. Men are usually more frequently affected than 
women. Persons of a neurotic temperament are often affected, and 



CONSTITUTIONAL DISEASES. 175 

it is most frequent among the higher classes. Frerichs found that 
the Hebrew race supplied one-fourth of his cases. In a considera- 
ble proportion of cases the subjects have been excessively fat when 
attacked. (A slight trace of sugar is not uncommon in the urine of 
obese persons.) It is more common in cities than in the country* 
Gout, malaria, and syphilis are predisposing causes. I have had 
three cases due, I believe, to syphilis. The most common cause is 
mental shock, severe nervous strain, or worry. When a man gives 
intense application to business, lives a sedentary life, and indulges 
in excesses of the table, he is in good condition to contract diabetes. 
It is often caused by injury or disease of the spinal cord or medulla- 
Some irritative lesion of Bernard's diabetic centre in the medulla 
may cause it. It has lately been ascertained by Von Mering that 
lesions of the pancreas cause diabetes. He found that extirpation 
of the pancreas in dogs caused glycosuria, but if a small portion of 
the gland was left, sugar did not appear in the urine. This would 
seem to prove that the pancreas, like the liver, has a double secre- 
tion, — an external, which is poured into the intestines, and an inter- 
nal which passes into the blood. This latter is supposed to be a fer- 
ment, in the presence of which alone the normal assimilative pro- 
cesses can take place with the glycogens. 

Diabetes is found all over the world, except perhaps in Guinea, 
where Blair asserts it is absolutely unknown. Compared with the 
percentage of deaths in Europe, the disease is rare in this country. 
According to the last census only 2.8 deaths from diabetes occurred 
to each 1000 inhabitants, while in England and Germany it is from 
5 to 9. But these statistics are very untrustworthy. Climate has 
much influence over diabetes. Dickenson in England and Purdy in 
this country prove that in cold and damp regions it is much more 
prevalent than in warm ones. According to a table in his work on 
diabetes, the rates of deaths in the United States is 1.9 in each 
1000 deaths. Vermont, Maine, and Connecticut show the largest 
percentage. In Vermont it is as high as 6.36 per cent. In Ala- 
bama, Arkansas, Mississippi, South Carolina, and Texas, it ranged 
as low as an average of 0.6. Purdy concludes from this that cold, 
damp, and mountainous regions are favorable to the production of 
this disease. California has almost as high a ratio as the New 
England States. Purdy says this disease has greatly increased since 



176 THE PRACTICE OF MEDICINE. 

our civil war. This he suggests is due to altered modes of life, 
wealth and its luxuries, richer food, and a more sedentary life. He 
asserts that after a careful study of all the physiological phenomena 
of diabetes, and the most recent advances upon the subject, his con- 
viction is as follows : 

" (1) That the essential feature of diabetes consists of a more 
or less profound disturbance of the glycogenic function of the liver. 

" (2) That the chemico-physiological changes in diabetes result 
in the arrest of the elaboration of certain foods in their course toward 
their ultimate destination in the organism, probably as fats, and the 
intermediate product, passing into the general circulation, escapes 
from the system, chiefly by way of the kidneys, in the form of sugar. 

" (3) That the disease is accompanied by a hyperaemic condition 
of the liver, and a more or less engorged state of the chylopoietic 
viscera. 

" (4) That receutly ascertained facts indicate that, in addition 
to the liver, the pancreas also is concerned in the production of sugar 
in the organism, or, to speak more accurately, in preventing the pro- 
duction of sugar in the organism, and consequently diseases of the 
latter organ are liable to induce diabetes. 

" (5) That diabetes may be brought about by diseases which 
involve the central ganglia that preside over the vasomotor nerves 
of the liver ; by diseases affecting the peripheral distribution of these 
nerves ; and probably, also, by disorders involving inhibitory reflex 
action of the sympathetic nervous system." 

Symptoms. — This disease may be divided into acute and chronic 
forms, but except in their duration there is no essential difference. 
It may also be divided into : (1) lipogenic or dietetic, which includes 
the transient glycosuria of obese persons ; (2) neurotic, due to injur- 
ies or functional diseases of the nervous system ; and (3) pancreatic, 
in which there is a lesion of the pancreas. 

Frequent urination and intense thirst are the first symptoms that 
mark the onset of the disease. When fully established, the chief symp- 
toms are great thirst, the voiding of large quantities of saccharine 
urine, a voracious appetite, and generally progressive emaciation. 

The Urine. — The amount varies from six to eight pints in mild 
cases to thirty or forty in severe cases. The specific gravity is high, 
from 1.025 to 1.045. It is pale in color, almost like water, and has 



CONSTITUTIONAL DISEASES. Ill 

a sweetish odor and taste. The reaction is acid. In two of my 
cases the amount of crystals of uric acid in the deposit was enormous. 
Sugar is present in varying amounts, from one to ten per cent. The 
total amount excreted during the twenty-four hours may range from 
ten to twenty ounces, and in very rare cases one to two pounds. Of 
the various tests for sugar, Fehling's is the one most used; but 
other tests are perhaps more delicate. Mitchell (Diseases of the 
Kidneys) prefers Haines'. Trommer's and Brucke's are in favor 
with some authorities. Purdy values Haines' test very highly ; he 
is doubtful of Fehling's, and considers the fermentation test too 
slow. For the methods of testing urine for sugar, consult Mitch- 
ell's work. 

Thirst. — This is one of the most persistent and distressing symp- 
toms of diabetes. The system requires a large amount of water to 
keep the sugar in solution. The amount of water imbibed bears a 
definite relation to the quantity excreted. In rare cases the thirst and 
consumption of water is small, and in these cases the quantity of 
urine passed is not excessive. The thirst is greatest about two 
hours after meals. The appetite is usually inordinate, and the diges- 
tion good. The tongue is usually dry, red and glazed, and the 
saliva scanty. The gums may become swollen, and in the last stages 
an aphthous stomatitis is common. Constipation is the rule. Ema- 
ciation steadily progresses, notwithstanding the enormous amount of 
food consumed. If the amount of sugar excreted is lessened by diet 
or medicine, a gain in flesh is soon apparent. The skin is dry and 
harsh, and perspiration rarely occurs. When tuberculosis coexists, 
drenching sweats may alternate with the polyuria. The temperature 
is often sub-normal. The pulse is usually frequent, and the tension 
increased. 

Complications. — Boils, carbuncles, and other affections of the 
skin, especially eczema and pruritus. In women the urine causes 
intolerable itching of the vulva and pudenda, and in men balanitis. 
Purpura and gangrene are not uncommon. 

Surgical operations in persons having glycosuria almost always 
result in gangrene. In two cases under my care amputation of a 
toe became necessary, the cutting of a corn having caused gangrene 
in a portion of the foot ; finally the whole foot was amputated, gan- 
grene following each operation. 

12 



178 THE PRACTICE OF MEDICINE. 

If the patient has pneumonia, gangrene usually ends the malady : 
but, singularly, the breath does not always have a gangrenous odor. 
Tuberculous broncho-pneumonia is common. It has been doubted if 
this was a true tuberculous affection, but Osier found the bacilli pre- 
sent in all his cases. Albuminuria, lithsemia, and cystitis sometimes 
complicate the disease. In the nervous system we often find such 
manifestations as peripheral neuritis, with lightning-like pains in the 
legs and loss of the knee jerk ; paraplegia, hypochondria, niorose- 
ness, and atrophy of the optic nerves. Diabetic coma is the most 
serious of all the complications, and carries off a large proportion of 
all cases. 

Frerichs recognizes three forms of cases : (1) Those in which, 
after exertion, the patients were suddenly attacked with weakness, 
syncope, somnolence, and gradually deepening unconsciousness ; 
death occurring in a few hours. 

(2) Cases with preliminary gastric disturbance, such as nausea 
and vomiting, or some local affection, as pharyngitis, phlegmon, or a 
pulmonary complication. In such cases the attack begins with head- 
ache, delirium, great distress, and dyspnoea, affecting both inspira- 
tion and expiration, a condition called by Kussmaul " air-hunger." 
Cyanosis may or may not be present ; if it is present, the pulse 
becomes rapid and weak, and the patient gradually sinks into coma ; 
the attack lasting from one to five days. There may be a very 
heavy, sweetish odor of the breath, due to the presence of acetone. 

(3) Cases in which, without any previous dyspnoea or distress, 
the patient is attacked with headache and a feeling of intoxication, 
and rapidly falls into a deep and fatal coma. 

There has been a great deal of dispute as to the nature of these 
symptoms. It certainly depends upon some toxic agent in the 
blood. It may be acetone, or oxybutyric acid — the alcoholic fermen- 
tation of sugar in the blood ; but Purdy's opinion coincides with my 
own. He says, " I am inclined to believe, however, that the toxic 
agent or agents which bring about the coma of diabetes, with its 
associated phenomena, is nothing more nor less than ptomaines. 
The extensive retrogade metamorphosis of albuminoid substances 
constantly going on in high grades of the disease, and the dimin- 
ished alkalinity of the blood, which entails its diminished oxidizing 
power, certainly combine the most favorable conditions for originating 



CONSTITUTIONAL DISEASES. 179 

these toxic agents. In addition to this, the prodromal symptoms of 
the coma, such as diminution of the urine and constipation of the 
bowels, by diminishing the avenues of escape, tend to cause accumu- 
lation of any toxic agents that may be generated in the system ; 
while some intercurrent disorder or over-fatigue, such as usually 
precedes the attack, disturbs the normal resisting power of the 
organism to the poison, completes the chain of causative factors, and 
precipitates the complication, the symptoms of which strongly indi- 
cate the nature of the cause. 

Diabetes is also accompanied by the following disorders of the 
special senses : cataract, retinitis, amaurosis, paralysis of the mus- 
cles of accommodation, and aural troubles, otitis media, with or with- 
out mastoid disease. Impotence is very common, and is sometimes 
the first symptom complained of. 

Diagnosis. — True diabetes mellitus should be distinguished from 
temporary glycosuria, which latter is only a transient form, due to 
certain errors in diet, or a slight mental shock. From simple poly- 
uria, it is distinguished by the persistent presence of sugar in the 
urine, and the influence of diet both on the sugar and the quantity 
of urine. In diabetes insipidus, diet does not lessen the quantity of 
urine, and the disease is curable ; this is a rarer disease. If sugar is 
found in the urine of polyuria, it is slight and very transient. Hys- 
terical women sometimes put sugar in the urine, as I have found in 
several cases much to my chagrin. 

Prognosis. — Osier, who may be said to represent the pessimism 
of the old school, says : " Personally, I have never seen a recovery 
from a case of true diabetes. Temporary arrest, reduction to a min- 
imum of the amount of sugar excreted, and prolonged periods of 
good health, I have frequently seen ; but neither in any one of my 
personal friends or acquaintances who have suffered with the disease, 
nor in patients who have come under my care in hospitals or private 
practice, have I known permanent and complete disappearance of 
the sugar so that an ordinary diet could be taken with impunity." 
He further says, " cures have been reported," which intimates that 
it is doubtful if they were permanent cures. Purdy is more hopeful, 
but not sanguine. He says : " Under twenty to forty-five years 
the outlook is more hopeful. At the same time it must not be over- 
looked that up to forty-five years of age diabetes is a very fatal dis- 



180 THE PRACTICE OF MEDICINE. 

ease. After middle age, say after fifty, the outlook is decidedly 
more favorable, as the disease then assumes a mild course and not 
infrequently terminates in recovery. 

The prognosis is much more gloomy when the disease is traceable 
to disease of the pancreas. It is better in stout than in lean people. 
The development of cataract indicates an unfavorable termination, 
usually in six to twelve months. Absence of the patella reflex is 
equally unfavorable. If a suitable diet removes the sugar from the 
urine, it is favorable to recovery. 

Treatment. — Prophylactic measures should be adopted for per- 
sons of diabetic parentage, or in families that present marked ten- 
dencies to the disease. In such cases it is advisable to limit their 
consumption of starchy and saccharine foods to the most moderate 
proportions. Occupations should be selected which bring with them 
the least possible mental strain or excitement. From Purdy's tables 
showing climatic influences, a residence should be selected in those 
states which show the lowest percentage of deaths from this disease. 
Purdy says, " A residence should be chosen as near the sea-level as 
possible, with a mean temperature range of 70° F. If a diabetic 
patient could spend eight months in southern Florida, from Nov- 
ember to April, and the other four months in some more northern 
state, he would be placed in the most favorable conditions for a recov- 
ery, so far as climate goes." 

The personal hygiene of the patient is of the utmost importance. 
He should lead an even, quiet, temperate life, avoiding all mental 
and physical excesses. The skin should be kept clean, but not 
over-clean. By this I mean that bathing should not be carried to 
excess, as it often is, by cold or hot baths every day, or frequent 
Turkish baths. All dirt should be removed from the skin, but the 
oil in the skin should not be washed out of it by soaps or alkalies. 
Soft warm flannels should be worn next the skin summer and win- 
ter. Silk is advised, but it cannot be safely worn next the skin in 
summer and winter — it cannot be safely worn when the tempera- 
ture ranges below 75° F. Moderate exercise or massage should be 
had every day. 

Dietetic Treatment. — The cardinal axiom is to avoid all carbo- 
hydrates in food, i. e., all foods which contain starch and sugar. 
The nearer we can come to an exclusion of these two substances, the 



CONSTITUTIONAL DISEASES. 181 

better for the patient. Without going extensively into a consider- 
ation of each article of food, I give Purdy's list of foods permitted 
and prohibited : 

"Foods Permitted. — Meats of all kinds except liver ; beef, mutton, 
pork, poultry, game, — either fresh, roasted, broiled, dried, smoked, 
cured, potted, or prepared in any way except with sugar, flour, or pro- 
hibited vegetables. Soups made from meats without flour, excluding 
vegetables. Fish of all kinds except oysters and the inner parts of 
crabs and lobsters. Eggs, bacon, butter, cheese, and oils. Jellies 
made from Cox's gelatine, unsweetened except with saccharin. Spin- 
ach, lettuce, olives, cucumbers, summer-cabbages, mushrooms, brus- 
sells-sprouts, and water-cress. Almonds, filberts, walnuts, cocoanuts, 
and Brazil-nuts. Beverages : Water, including all mineral waters ; 
Ehine wine ; California Kislings, and Chablis ; New York and Ohio 
catawbas ; Budai Imperial, Schreiber's " dietetic wine," whisky, 
and gin. 

" Foods Prohibited. — Common bread, except as specified below ; 
biscuits, crackers, and cakes. Farinaceous articles, such as pota- 
toes, rice, sago, tapioca, macaroni, vermicelli, common flour, oat- 
meal, cornmeal, buckwheat flour, barley meal. The liver of all ani- 
mals, oysters and sugar. Saccharine vegetables, such as turnips, 
carrots, parsnips, peas, beans, beets, onions, and rhubarb. Blanched 
vegetables, such as celery, sea-kale, endive, radishes ; and all roots, 
fruits, and chestnuts. Beverages : Tea, coffee, kola, milk, whey, 
buttermilk, skimmed milk, chocolate, cocoa, malt liquors, cider, 
champagne, sauternes, sherry, port wine, madeira, and all sweet 
wines and liquors. 

" The discovery of saccharine has furnished us a substitute for 
sugar which has a sweetening power nearly three hundred times 
greater than the latter. The tablet form in which saccharine is now 
put up is very convenient for sweetening beverages ; my patients 
have usually found that food and beverages flavored with saccharin, 
if not over-sweetened, are quite as agreeable and pleasant as when 
flavored with sugar." (" Dulcine," a new product, is said to be 
better.) 

In the absence of saccharin, pure glycerine can be used. In 
regard to the so-called gluten bread and biscuit, Purdy rejects all 
that are made and sold as such. He quotes from the expose of Dr. 



182 THE PRACTICE OF MEDICINE. 

Ch. Harrington, of Boston, who fearlessly published his analysis of 
these " gluten breads " and " gluten flour." According to his analy- 
ses, home-made bread contains 44.99 per cent of starch ; graham 
wafers, from graham flour, 58.45 ; gluten flour of Farwell and Co., 
of Watertown, N. Y., 67.17 ; the special diabetic foods of this firm, 
68.18 ; the gluten flour of the New York Health Food Company, 
66.18 ; bread made from this flour would contain 35. ; the gluten 
wafers of this company 66.96 ; the Boston Health Food Company's 
gluten flour, about the same per cent. 

" In view of these startling facts," says Purdy, " there seems but 
one course to pursue with reference to bread if we expect to cure our 
diabetic patients, and that is to limit or curtail its use in all forms." 
It is best at first to cut down the use of bread one-half. If the sugar 
does not decrease, still further curtail it. If no change appears, then 
prohibit bread of all kinds altogether. 

The wines permitted by Purdy contain only one or two grains of 
sugar to each fluid ounce, and can be drunk in moderation. The 
mild alkaline waters, like Vichy, Carlsbad (foreign and Colorado), 
can be used as a beverage. The skimmed-milk diet, so highly lauded 
by Donken and Tyson, is not suitable in severe cases, for " the milk- 
sugar it contains acts in the alimentary canal precisely as does grape- 
sugar." (Parry.) 

Coffee is usually permitted, but Purdy, who analyzed an ordinary 
cup of coffee, says it contains seven and one-half grains of starch to 
the fluid ounce. A good quality of Ceylon or Assam tea, while it 
has all the body of coffee, contains a very small percentage of starch. 
This should be used without milk, but with saccharin if a sweet is 
desired. 

Pure water, or the mildly alkaline, can be used by the patient 
ad libitum, but his food should be limited. It is possible to eat too 
much diabetic food. If the stomach is overtaxed, indigestion will 
occur, and fermentation set in. The patient should eat oftener per- 
haps than three times a day, but the quantity should be small. Eat- 
ing to satiety should never be indulged in. 

Medicinal treatment of saccharine diabetes. — The drugs used by 
the old school are opium, morphine, codeine, antipyrin, ergot, arsenic, 
the bromides, iodoform, jambol, etc. Purdy says opium retains its 
reputation best, as its action in restraining the excretion of sugar is 



CONSTITUTIONAL DISEASES. 183 

more uniform than any other drug. Diabetic patients are remark- 
ably tolerant of this drug, and can take it in large doses. Crude 
opium is rarely used ; morphine, according to Dr. Bruce, is the most 
powerful, but codeine is usually preferred. Dr. Ralfes says that a 
full dose of opium or morphine at bed-time is the best method of 
administration, as it is less likely to disturb the digestion or cause 
beadache. By a full dose is meant one or two grains of opium : 
twenty drops of laudanum or one-fourth grain of morphine. All 
admit, however, that cures are rare under its use, because it cannot 
be long continued without causing the opium habit. 

Codeine is now preferred, because there is but little danger of 
causing the " habit " by its use. Its action on the brain is quite dif- 
ferent from that of morphine. The dose is one-fourth to one-half 
grain three times a day, and old-school writers assert that it can 
safely be increased to five or ten grains daily. I have used codeine, 
one-fourth grain four times a day, in two cases, with good results. 
The sugar was lessened from twenty to thirty per cent in two weeks, 
and the water from six to three quarts ; when the codeine was stopped 
the sugar or water did not increase. It is now nearly a year since 
the drug was suspended, and the patients are still in good condition. 
They may not be cured, however. One objection to codeine is its 
high price. " Six grains of codeine," says Osier, " costs twenty-five 
cents ; whereas the same amount of morphine costs only ten cents." 
As it is rarely the very poor who have diabetes, this is not much of an 
objection. Codeine costs my patients only six cents a day. Purdy 
prefers the bi-meconate of morphia if codeia is not used. A mixture 
of morphia and atropia has been used with alleged success. Some 
recent experiments lately made on the drugs which influence the 
secretion of the pancreas prove that morphia and atropia are the 
most powerful in arresting the secretion of that gland. It may 
be found that it is in pancreatic diabetes that these drugs are 
the most valuable. Antipyrin, so highly praised, is denounced by 
Purdy, who says that in many cases he had reduced the sugar to 
five grains to the ounce and the water to two quarts by diet alone ; 
all restrictions as to diet were thrown off, and antipyrin was given 
— forty-five grains a day — with this result : the sugar increased 
to fifteen grains to the ounce, and the water in proportion ; sev- 
eral of the patients went into coma and died in a few days. Other 



184 THE PRACTICE OF MEDICINE. 

drugs of the phenol series have been used, — phenacetine, salol, 
acetanelid, exalgine, etc., — and some cures are claimed ; but their use 
is attended with danger, and permanent cures are doubtful. 

Creosote, which is allied to these drugs, is credited with some 
cures that seem permanent. It has been given in doses as large as 
ten drops three times a day. In our literature it is reported to have 
cured in the 2x dilution. I very nearly cured a case with ten drops 
of the lx four times a day. The sugar was reduced to five grains 
to the ounce, when the patient left the city and has not reported 
since. Four drops of the mother tincture three times a day, accord- 
ing to Valentine, in two cases caused sugar to disappear altogether. 
The bromides have been used with success in many cases. From an 
analysis of the reports, it would seem that they are best adapted to 
cases caused by mental disturbances. Nearly thirty-five years ago I 
had under my care a most obstinate case caused by mental depression. 
All the then approved drugs were tried unavailingly, when I saw 
in a number of " Braithwaite " a report by Dr. Begbie, of two cases 
cured by bromide of potassium, ten grains every four hours. Suspend- 
ing the strict diet of milk and meats, I gave the bromide in the doses 
recommended, and cured my patient, at least for eight or ten years. 
The medicine was continued six weeks, causing some acne and dys- 
peptic symptoms, which were removed by arsenicum. At one time 
the bromide of arsenic (one-half grain three times a day) was highly 
praised, and some French authorities reported cures. It has not 
been successful in this country, with either school. Purdy says he 
never got satisfactory results from it. A combination of lithium 
with arsenic has been highly lauded by Eouget and Martineau. 
The latter claims to have cured sixty-seven out of seventy cases 
with it. No other reports as favorable have yet appeared. (Two 
drops of Fowler's solution, with eight grains of lithium carb., after 
meals.) 

Arsenite of iron (2x trituration, one or two grains after meals) 
has been very beneficial in my hands when diabetes has been attended 
by anaemia, or was the result of malarial cachexia. Purdy claims 
good results from larger doses, one-sixteenth to one-sixth of a grain. 

Jambol, the seeds of an East Indian plant (syzygium jambo- 
lanum), was first used by English physicians in India, who reported 
excellent results. The dose was three to five grains of the powdered 



CONSTITUTIONAL DISEASES. 185 

seeds, but it has been given in doses as large as thirty grains three 
times a clay. It is notoriously uncertain in its action. In large 
doses it is said sometimes almost to suppress the urine, without 
lessening the quantity of sugar. Outside the body it has a decided 
inhibitory influence upon the action of diastasic ferments. In two 
experiments narrated in u Pharmacology of the Newer Eemedies," 
a given amount of malt extract converted 22.4 grains of starch 
into sugar in the absence of jambol, but only 6.3 grains iu its pres- 
ence. If it acts in the same manner in the digestive canal or the 
blood it ought to prove a good palliative at least. Some interesting 
experiments were made by Prof. Binz, of Germany, on dogs made 
diabetic by phloridzin. When the dogs were excreting ten or twelve 
grammes of sugar daily, jambol was given, and the sugar fell to one 
or two grammes daily, showing conclusively the power of jambol 
over the excretion of sugar. Dr. W. H. Burt, of Chicago, in his 
" Physiological Materia Medica," records some interesting experi- 
ments and provings of jambol, and reports several surprising cures 
of glycosuria with it, one of which I was cognizant of, and is I 
believe now a permanent cure. In the " Pharmacology of Newer 
Remedies " nine cases of severe diabetes are reported, treated with 
jambol. All were greatly benefited, but only one cured. Some 
failures are also reported. No cures have been reported with the 
attenuations. The tincture or fluid extract does not seem to act as 
well as the seeds in powder. 

Phloridzin was alluded to above as causing saccharine diabetes 
in dogs. This would make it a true homeopathic remedy. In one 
case I resolved to test its value according to the law of similia. It 
was not a bad case, the sugar not exceeding twenty grains to the 
ounce. Under the use of five grains of the lx trituration, every 
four hours, the excretion of sugar slowly decreased until it was as 
low as five grains per ounce. (It required twenty-five to forty 
grammes - — three hundred to six hundred grains — daily to cause 
diabetes in dogs.) Phloridzin is the bitter principle found in the 
bark and roots of the apple, plum, and cherry trees. It is said to 
possess decided tonic properties, but we have no proofs. 

Uranium nitrate is a drug which has caused an excretion of sugar 
in the urine, and has been credited with numerous cures in our lit- 
erature. In my " New Eemedies " I give a full history of its path- 



186 THE PRACTICE OF MEDICINE. 

ogenetic and curative effects. The triturations from the 3x to 6x 
have given the best results. 

Phosphoric and lactic acid are highly recommended. The for- 
mer, when the disease is evidently of nervous origin ; the latter, 
when the gastric derangement (acidity and pyrosis) is present. 

If the portal system is engorged and the liver torpid, euonymin, 
podophyllin, irisin, and leptandrin are useful. The late Dr. Laning 
found leptandra 3x very useful in a case reported in the " Clinique," 
1890, p. 227. 

Aurum and its preparations have benefited many severe cases. 
Mercurius also has made some cures. 

When the pancreas is suspected as being the cause of the dis- 
ease it must be owing to a perverted secretion of that gland. Pilo- 
carpine is supposed to increase the natural secretion of the pancreas, 
and may prove a palliative if not a curative remedy. 

The late Dr. Lilienthal compares our chief remedies in relation 
to pancreatic affections and diabetes as follows : 

" Uranium nitricum. — Pancreatic symptoms : Ulceration of the 
duodenum, and also of the pyloric end of the stomach ; vomiting of 
a white fluid ; putrid eructations ; pains worse from fasting ; tym- 
panitis ; emaciation and prostration ; styes ; copious salivation. 

Diabetic symptoms : Sugar in the urine : defects of digestion and 
assimilation ; general languor, debility ; cold feeling ; vertigo ; pur- 
ulent discharges from eyelids and nose ; copious salivation ; enor- 
mous appetite and thirst, but the patient emaciates ; excessive flow 
of urine. 

Phosphorus. — Pancreatic symptoms : Tuberculosis ; fatty degen- 
eration of various organs, especially the heart, liver, and kidneys ; 
distressing burning pains in the cceliac axis ; stools undigested, con- 
taining particles of fat ; face pale, yellow ; neuralgia of cceliac 
plexus ; anaemia ; atrophy of pancreas, with diabetes mellitus. 

Diabetic symptoms : Diabetes with phthisis ; urine profuse, pale, 
watery or turbid, whitish, like curdled milk; dark yellow, with a 
gray pellicle, covered with a fatty membrane ; gouty diathesis ; fun- 
gous excrescences ; paralyzed sensation in extremities. Phosphoric 
acid suits more neurogenic diabetes. 

Arsenicum album. — Pancreatic symptoms : Organic changes, 
with restlessness and anxiety ; ulceration of the duodenum, involv- 



CONSTITUTIONAL DISEASES. 187 

ing the pancreatic duct ; stools undigested, containing fat ; neural- 
gia of coeliac plexus ; melancholia, with suicidal tendencies ; face 
pale and puffy ; extreme thirst and great irritability of the stomach ; 
pain about navel, causing him to bend forward ; diarrhoea, with vom- 
iting and prostration. (Yichy contains arsenic.) 

Diabetic symptoms : Urine, drawn by the catheter, gives all the 
characteristic indications of glycosuria ; polyuria with bulimy and 
unquenchable thirst ; emaciation and great weakness ; watery, dark 
diarrhoea ; disposition to gangrene ; slight motion causes dyspnoea, 
with palpitation and fainting ; dropsies. Compare arsenicum bro- 
mide and arsenicum iodide. 

lodum. — Pancreatic symptoms : Great emaciation ; hungry, 
anxious if he cannot get food at the appointed time ; eats enormously, 
yet grows thin ; soapy taste ; fat in the stools ; glands enlarged or 
atrophied ; lungs affected. (Kademacher's stand-by in pancreatic dis- 
ease). 

Diabetic symptoms : Diabetes with canine hunger ; frequent and 
copious urination, bright yellow and watery or turbid, milky, with 
dark sediment ; cold hands and feet ; rough skin ; dizziness, with 
tendency to fall forward. 

Creosotum. — Pancreatic symptoms : Chronic irritability of the 
stomach, food is not retained or digested ; gastromalaria ; ulcera- 
tive pain in epigastrium on deep breathing ; pains in hepatic region, 
extending to small of back ; despondency and loss of memory ; ten- 
dency to hemorrhages, and rapid decomposition of secretions. 

Diabetic symptoms : Perfect depression of the trophic nervous 
system ; frequent and copious urination night and day ; great itch- 
ing of genitals during and after micturition ; head confused and dull ; 
dimsightedness ; physical exhaustion, worse from rest ; bruised sen- 
sation in chest and back. 

Iris versicolor. — Pancreatic symptoms : Burning distress in 
pancreatic region ; vomiting of sweetish water ; saliva has a greasy 
taste ; green watery stools, containing undigested fat ; bilious vom- 
iting; migraine. 

Diabetic symptoms : Frequent limpid micturition, or scanty, high- 
colored, and of strong odor ; furunculosis ; weakness and pain in 
limbs, so that walking is nearly impossible. 

Lycopodkim clav. — Pancreatic symptoms : Chronic duodenitis ; 



188 THE PRACTICE OF MEDICINE. 

pancreatic calculi ; pressure on hypochondrium produces tender 
pains in the epigastrium, and vice versa ; icterus ; flatulency ; con- 
striction of anus and rectum. 

Diabetic symptoms: Gouty lithsemia; canine hunger, but the 
attempt to eat is followed by flatulent distention and satiety ; con- 
stant desire to urinate, with scanty discharge ; mental, nervous, and 
bodily exhaustion ; phthisis and hectic. 

Natrum sulfuricum (Carlsbad, Vichy) , Hydrogenoid consti- 
tution. — Pancreatic symptoms : Dizziness and headache from gas- 
tric derangement and non-assimilation of food ; sallow or jaundiced 
features ; vomiting of bitter, sour fluids ; flatulent colic ; dyspnoea, 
worse during damp weather ; leucaemia ; consumption ; prostration, 
and tired weary feeling, especially about knees. 

Diabetic symptoms : Depressed and tired of life ; dryness and 
burning in the eyes ; dryness of mouth and throat ; great thirst for 
very cold drinks ; voracious appetite, but food disagrees ; f cetid flatus ; 
increased micturition, especially at night, with burning sensation 
when passing urine ; great weariness, with dull headache ; always 
chilly." 

Sulphide of calcium, a drug allied to our hepar sulphur calcium, 
is reported to have cured some cases in doses of one-tenth to one 
grain three times a day. In one of our English journals I once saw 
a report of a cure of diabetes with hepar sulphide calcium 30th 
dilution. 

Strychnine has been useful. Korjinsky cured a case with one- 
sixtieth grain, increased to one-sixteenth grain, three times a day. 
Jacobi treats diabetes of infants and children by milk diet, salicy- 
late of sodium five to eight grains three times a day, in Vichy, and 
one drop of Fowler's solution after meals. 

Squire recommends phosphorus, one-thirtieth of a grain three 
times a day. 

Peroxide of hydrogen, or glycozone, is recommended by Purdy 
and others, in doses of one or two teaspoonfuls in a glass of pure 
water, several times a day. Inhalations of oxygen have been of ben- 
efit in some cases. 

Rhus aromatica, so valuable in many renal and cystic disor- 
ders, has been found of decided value in diabetes. In " Pharma- 
cology of Newer Remedies " severe cases of diabetes are reported, 



CONSTITUTIONAL DISEASES. 189 

all pronounced cured by doses varying from fifteen drops to sixty 
drops three times a day. Two of the reported cases were diabetes 
insipidus. 

Dr. E. Mansel Sympson, in the " Practitioner," records a case 
of acute saccharine diabetes in a youth of seventeen years, in 
which marked improvement took place under sodium salicylate. 
When first seen, on April 18, he presented the usual symptoms in 
a marked degree, and was passing seven pints of sugary urine (spe- 
cific gravity 1050) in the twenty-four hours. On a mixed (though 
partly restricted) diet and ten grains of salicylate every four hours, 
at the end of a week the daily quantity of urine had diminished by 
two pints. During the second week he was put on a strict diet, and 
had salicylate every six hours. On the twelfth day of treatment he 
was passing two pints of urine daily, of specific gravity 1014, with 
a trace of sugar (less than one grain to the ounce). On the eigh- 
teenth day sugar had disappeared from the urine. Meanwhile the 
symptoms gradually subsided, and he gained weight rapidly. On 
two occasions, when the drug was temporarily suspended, the amount 
of urine was doubled in quantity. The blood presented no abnor- 
malities, and the motions did not contain fatty matter. In July the 
patient was well and healthy-looking, and able to take plenty of 
exercise. 

Lycopus has been found curative in diabetes mellitus. Dr. Kay 
reports several cases in the " Eclectic Medical Journal." They were 
characterized by the flow of a gallon or more daily of clear urine, of 
great density and containing sugar, intense thirst, great emaciation, 
and other well-known symptoms of the disease. After trying a rigid 
diet and various medicines without much good result, the fluid 
extract of lycopus was given in doses of thirty drops three times a 
day, with surprisingly prompt effect. All the symptoms rapidly 
gave way, until the patients were apparently cured. Thus we have 
another remedy for that serious and often intractable malady. I 
published in the " North American Journal of Homeopathy," No- 
vember, 1878, a remarkable cure of diabetes mellitus by means of 
the lycopus in infusion, one ounce of the herb to eight ounces of 
water, a tablespoonful irve times a day, continued several weeks. 

Drs. De Renzi and Reale, of Naples, give some important experi- 
ments, illustrating the causation of diabetes : (1) It may be pro- 



190 THE PRACTICE OF MEDICINE. 

duced experimentally by the extirpation of various organs, which* 
mentioned in the order of their importance, are : the pancreas, duo- 
denum, and the salivary glands. (2) It is produced in animals 
after total extirpation of the pancreas in seventy-five per cent of the 
cases. (3) Clinical observation has shown that very grave diabetic 
symptoms follow the suppression of the salivary secretion, and the 
authors' experiments were confirmatory of their observations. (4) 
It is very probable that there exists in the organism a ferment 
occurring in various amounts in different organs, which ferment 
destroys sugar. 

Their deductions are that the treatment of diabetes should be 
chiefly dietetic, the best diet consisting of green vegetables and 
meat in proper proportions. It seems to me that further deductions 
should be made. Why not give medicines which we know increase 
the normal secretions of the salivary glands and the pancreas ? The 
two most prominent ones are iris and jaborandi, or their active prin- 
ciples, irisin and pilocarpine. It is possible that the internal admin- 
istration of pancreatin and pty aline may be useful, especially when 
the indigestion seems to call for these two ferments. 

Dr. Seeger, of Vienna, says there is a kind of diabetes in which 
the elimination of sugar is entirely independent of the food taken. 
We should not be too strict in all cases, but ascertain by experiment 
whether diet has any influence, and if not, allow our patients suffi- 
cient food of all kinds to keep up a high degree of vitality. 

Dr. M. L. Huntington, of Darlington, Wis., in a valuable paper on 
" Glycosuria during pregnancy " (" Homeopathic Journal of Obstet- 
rics," January, 1893), reports a case in which uranium nitrate " was 
the one and only remedy given until the sugar had almost disap- 
peared from the urine." Then albumen appeared in abundance, 
with dropsy. Both were cured by helonias. Diabetes during preg- 
nancy is a dangerous event. It may cause the death of the foetus, 
and be quickly fatal to the mother. Over one-half of the pregnan- 
cies in diabetic women end in the death of the foetus and miscar- 
riage. " We learn from the experience of Dr. Duncan and others 
that the glycogenic process is usually exaggerated in a diabetic woman 
by the coexistence of pregnancy. The manner in which this result 
is accomplished would be difficult to demonstrate. It has been 
ascertained, however, that during normal lactation the amount of 



CONSTITUTIONAL DISEASES. 191 

glycogen in the blood is increased. This supplies the mammary- 
glands with the necessary sugar to properly elaborate the mother's 
milk. This increased production of sugar is no doubt controlled in 
a reflex manner by the activity of the mammary glands, increasing 
or diminishing according to their needs. If for any reason the stim- 
ulation of the glycogenic centres be exaggerated, the amount of sugar 
produced will be in excess of the need of the mammary glands and 
will be excreted by the kidneys, producing a temporary glycosuria or 
aggravating an already existing diabetes." 



DIABETES INSIPIDUS. 

Definition, — A chronic affection, characterized by the passage 
of large quantities of normal urine of low specific gravity. This 
must be distinguished from diuresis or polyuria, which is observed 
in hysteria, nervousness, after neuralgia, and in Bright's disease. 

History. — It is most common in young persons. It may be congen- 
ital : I have frequently met with it in infants. It is hereditary in some 
families. Many of the causes which provoke glycosuria may excite 
this disease, such as injuries to the head and spine, fright, mental 
depression, etc. The disease has followed rapidly the copious drink- 
ing of cold water or liquor, or has set in during a convalescence. 
It has been caused by tumors of the brain and medulla, and has 
accompanied paralysis of the sixth pair of nerves. Irritation of Ber- 
nard's "diabetic centre" may cause this disease, as well as sugar 
diabetes. It has been observed coincident with abdominal tumors, 
abdominal aneurism, and tuberculous peritonitis. Osier says that 
the nature of the disease is unknown, but he thinks the most rea- 
sonable view is that it results from a vaso-motor disturbance of the 
renal vessels, due either to local irritation from organic disease or 
to functional irritation of the vaso-motor centre in the medulla. 
The kidneys have been found enlarged and congested, and the 
bladder hypertrophied, but these are doubtless consequences of the 
disease. 

Symptoms. — Many of the symptoms are like those of glycosuria ; 
others are different. The specific gravity of the urine is lower, 
1.001 to 1.005 ; the solid constituents may not be reduced. Urea 



192 THE PRACTICE OF MEDICINE. 

has been found in excess. The appetite is good, but not excessive 
as in true diabetes. The patients do not usually loose flesh but may 
be well nourished and healthy-looking. In many instances this 
disease does not seem to interfere with the general health ; the 
great annoyance is the excessive thirst and the frequent calls to 
urinate. The urine passed may exceed ten to thirty pints a day, 
and has been known to reach the enormous amount of fifty-six 
pints. 

The perspiration is slight, the skin harsh and dry, the mouth 
dry, and the saliva scanty. The tolerance for alcohol is remarkable ; 
two pints of brandy or two dozen pints of wine have been drunk in 
a day by some patients. There is an absence of sugar, except inos- 
ite, or muscle sugar ; albumen is very rare. Hysterical polyuria 
may closely simulate this disease. So may Bright's disease, but the 
presence of albumin and hyaline casts and high arterial tension dis- 
tinguish the latter from diabetes. 

Diuretics may cause a polyuria by acting on the kidneys, but true 
polyuria is never caused by renal disease. We are often told by 
patients that they pass great quantities of water, and fear they have 
diabetes because they are compelled to urinate every few minutes 
day and night ; but if we oblige them to measure their urine, we 
will find that the amount voided in twenty-four hours is not above 
normal. They are suffering from irritable bladder. The prog- 
nosis is not generally as serious as in glycosuria, except when there 
is a loss of much solids in the urine ; then it is quite serious. In 
some cases, as in diabetes mellitus, numerous crops of boils reduce 
the strength of the patient. If anaemia occurs, the prognosis is seri- 
ous unless we can enrich the blood. 

Treatment. — It must be remembered that, as a rule, the true 
diuretic medicines, — those that act on the renal epithelum and tubules 
directly, — are not homeopathic to this form of diabetes. Those only 
are homeopathic which act through the vaso-motor centre, or on 
the general nervous system. The same remedies recommended for 
diabetes mellitus have been found useful in this form, namely: 
codeine, jambol, pilocarpine, rhus aromatica, the bromides, etc. Those 
which cause sugar in the urine are probably to be excluded. In addi- 
tion to those above mentioned, I can name : helonias, turpentine, 



CONSTITUTIONAL DISEASES. 193 

aurum, glonoine, valerian, phosphoric acid, zinc (phosphide and val- 
erianate), ergot, strychnine, ignatia, arsenic, ferrum arsenite, and apo- 
cynum cann. If the heart is very weak, the cardiac tonics in small 
doses may be useful. I have seen benefit from belladonna, atropine, 
and hyosiamine in some cases. The diet need not be restricted, as 
in true diabetes. The food should be abundant and nourishing. 
Water, except the diuretic waters, may be taken in abundance, and 
black tea, coffee, kola-nut, chocolate, cocoa, and claret in modera- 
tion. I have reason to believe that when there are anaemia and fur- 
uncles, the waters of West Baden and French Lick Springs, espe- 
cially the two lithia springs, taken in small quantities, not more 
than one ounce three times a day, will be efficacious. The arsenite 
of iron spring of Tyrol — "Levigo water" — in doses of a teaspoon- 
ful after meals, I know to be useful. 

The patient should clothe warmly in flannels (as in glycosuria). 
Vapor baths are recommended. The climate should be warm and 
moist, as in southern Florida, Cuba, Jamaica, or the Bahama 
Islands. If it is not possible to make such a radical change of cli- 
mate, the patient should remain in the house during cold, damp 
weather. 

The following case is taken from the " British Medical Jour- 
nal ": " Dr. A. P. Voinovitch, of St. Petersburg, now reports a case 
of diabetes insipidus apparently completely and permanently cured 
by antipyrin. The patient, a retired artilleryman, aged thirty-three, 
whose father and brother had died from diabetes mellitus, was sud- 
denly seized with insatiable thirst and polyuria during a severe 
attack of epidemic influenza. The daily quantity of urine occasion- 
ally rose to thirteen litres. Antipyrin was given in one-half gramme 
doses from eight to twelve times a day, the administration being 
divided into three distinct courses (one of six days duration, another 
of ten days, and the third of seven), with intervals of three and 
twenty-three days respectively. The patient was discharged in per- 
fect health on the fourteenth day after discontinuing the treatment, 
the daily amount of the urine excreted oscillating between 650 and 
1100 grammes, and the amount of drink taken averaging 2100. 
He still remained well at the date of report (about twelve months 
after the discontinuance of the treatment). 

13 



194 THE PRACTICE OF MEDICINE. 



MYALGIA. 

Definition. — Myalgia proper includes all those affections which 
are generally known as "muscular rheumatism," "lumbago," "pleuro- 
dynia," "stiff neck," etc. It is an exceedingly painful affection, 
and much more common than was formerly supposed. It is to Dr. 
Inman, of England, that we owe the demonstration of the frequent 
occurrence of this malady, and the facility with which it may be 
mistaken for other and sometimes much more serious diseases, with 
very disastrous results. When I first read his book, nearly thirty 
years ago, I realized how important were his disclosures. Doubt- 
less he was too enthusiastic, but I can readily understand how 
his enthusiasm carried him beyond the bounds of strict conserv- 
atism. 

I could see that a large proportion of the disorders which had 
been called chronic rheumatism and neuralgia did not belong to 
either disease, but were due to a painful condition of the muscles. 
Inman defines myalgia as follows : " It is essentially pain produced 
in a muscle obliged to work when its structure is imperfectly nour- 
ished or impaired by disease. It may affect alike the anaemic 
under-fed man or woman, the muscular laboring man, or a full-fed 
plethoric man of leisure, if they over-exert, or expose to cold and 
damp, any muscular structure." 

The pain of myalgia is familiar to all. Its type is the " stiff 
neck," or pain in the back from lifting, or the so-called " crick " in 
the back. Those who have felt the painful lameness and soreness 
from an unusual horseback ride, or a long unaccustomed walk, need 
no other explanation. In our present manner of living very few 
persons exercise, every day, all the muscles ; in fact only a few are 
brought into constant requisition. When, then, we come to use 
those unused muscles, they suffer from even a moderate use, and the 
result is soreness, lameness, and a host of other painful sensations, 
all of which are included under the name myalgia. 

Anstie defines myalgia as " a disease of local origin, and depend- 
ing for nine-tenths of its causation upon a derangement between the 
balance of work and nutrition in the muscle." 



CONSTITUTIONAL DISEASES. 



195 



The following is the differential diagnosis of myalgia from neu- 
ralgia: 

NEURALGIA. MYALGIA. 



Follows the distribution of a recogniza- 
ble nerve or nerves. 



Goes with an inherited or acquired ner- 
vous temperament. 

Is much less aggravated by movement 
than myalgia is, and is at first accom- 
panied by no local tenderness. 

Points which are painful, when estab- 
lished at a later stage, correspond to 
the emergence of nerves. 

The pain not materially relieved by any 
change of posture. 

Paroxysms of pain, appearing without 
appreciable cause. (The only excep- 
tion to this is tic, in which a parox- 
ysm is caused by eating, talking, or 
laughing.) 



Attacks a limited area or spot that can 
be identified with the tendon of a 
muscle, which will be found to have 
been unusually exercised, or exposed 
to a draught of cold damp air, or un- 
suitable clothing. 

As often as not occurring in persons with 
no special neurotic tendency. 

Is inevitably and very severely aggra- 
vated by every movement of the part. 

Distinguished from neuralgia by local- 
ized tenderness on pressure as well 
as movement. 

Tender points correspond to tendinous 
origins and insertions of muscles. 

Pain usually completely and always con- 
siderably relieved by full extension of 
the painful muscle or muscles. No 
paroxysms unless brought on by mo- 
tion. 



There is a species of myalgia not mentioned by Inman or Anstie. 
I refer to that condition designated as muscular rheumatism, which 
is caused by over-strained muscles or tendons, followed by, or attended 
with, exposure to cold or dampness. We often see it in horses that 
have been ridden hard, and left standing in a cold or damp place 
without sufficient protection or grooming. In both men and horses, 
the results are a peculiar lameness which causes a desire to move 
the muscles because they ache, but on beginning to move them the 
pain is severe, wearing off, however, on continued motion. This is 
the condition in which rhus is so much and so successfully used. 
^Esculus and natrum sulph. have this symptom in a less degree. 

Treatment. — (1) Place and keep the muscle in a position of 
full extension, which is only to be changed at rare intervals. 

(2) Cover the skin all over and around it with oiled silk, rub- 
ber cloth, or spongio-piline, so as to keep the part constantly sweating. 

(3) Occasionally rub in chloroform water, or aconite water, or 



196 THE PRACTICE OF MEDICINE. 

eucalyptol water, or they can be mixed in equal parts. I use it 
under the name of " Compound chloroform liniment." 

Give internally rhus tox. or rhus venenata, phenacetine, natrum 
sulph., arnica, cimicifuga, or cannahis indica, or any of the remedies 
mentioned in our text-books, the symptoms of which correspond accu- 
rately to the true myalgic conditions. 

Anstie considers muriate of ammonia to be nearly specific. He 
prescribes it in twenty or thirty grain doses ; I find five grains 
repeated every three hours amply sufficient. An elegant method of 
administration is the five-grain compressed tablet, which can be 
swallowed whole. 

It is in this disease, especially when it has lasted some time, that 
acupuncture has made many brilliant cures. 

The f aradic current often cures myalgia, only a few applications 
being required. In poorly nourished patients, or those who are 
anaemic, some constitutional treatment should be given to build up 
the system. I find that hydrastis, combined with the hypophosphite 
of soda, and strychnia, give the best satisfaction. Cod-liver oil with 
hypophosphites is useful in emaciated subjects. Sabal, helonin, 
aletris, ferrum, and alstonia are also useful, on account of their 
general restorative powers. 

GOUT. 

Definition. — An inflammation characterized by the deposition of 
urate of soda in a crystalline form into the cartilages and other tex- 
tures of the joints and fibrous tissues. It is usually attended also by 
constitutional symptoms and grave lesions of important organs. 

Causes. — Gout is mainly a disease of middle life and of the 
male sex. It is more hereditary than any other disease. Dr. Gar- 
rod estimates that one-half of all gouty patients get it by heredity. 
It is also said to be induced by certain habits of life, among which 
are the long use of alcoholic beverages, constant over-eating of ani- 
mal food and rich dishes, and, added to these, insufficient exercise. 
The direct cause is chemical. It is due to an excess of uric acid or 
urate of soda in the blood. Dr. Murchison believes functional disor- 
ders of the liver cause this excess of urates. Dr. Garrod believes the 
kidneys fail in their function to eliminate the urate from the blood. 



CONSTITUTIONAL DISEASES. 197 

Drs. Ord and Bristowe believe that a certain kind of degeneration 
in the fibroid textures of the body tends to a deposit of urate of 
soda in those tissues ; that it causes inflammation therein, and that 
during this process the urates are discharged into veins or lym- 
phatics, or both*. 

Dr. Pye Smith, an eminent authority, has just delivered a lecture 
before the Royal College of Physicians in London, in which he 
vigorously challenged the notion that a majority of gout cases are 
due to over-indulgence in spirits, wines, or malt liquors. He pointed 
out that in Scotland, where whisky is a favorite beverage, gout is 
rare. As to port or sherry, he said that in Spain, the home of these 
wines, the disease is very seldom met with. Then again as to malt 
liquors : if they are the cause of gout, he asked why the malady did 
not prevail extensively in Munich and Vienna, where the consump- 
tion of beer is universal and enormous. Yet in those cities the 
malady is but little known. The chief peculiarity about gout is that 
it principally affects the most civilized nations and the upper classes 
of society. It prevails among men far more than among women, 
and attacks the strongest and best-fed persons in otherwise vigorous 
health. The fact is, according to Dr. Smith, that the cause of the 
disease is as much a mystery as ever, but it is more reasonable to 
suppose that it exists in the food than in the drink. 

Dr. Roberts says : " In the normal state the uric acid, which cir- 
culates in the blood as a quad-urate, is at once removed unchanged 
by the kidneys. But in the gouty state, either from defective kid- 
ney-action or some other cause, this quad-urate lingers unduly in the 
blood. This detained quad-urate, circulating in a medium which is 
rich in sodium carbonate, is gradually transformed into sodium 
bicarbonate, which is almost insoluble in blood -serum, and is probably 
for that reason difficult of removal by the kidneys. Under these 
new conditions, sodium bi-urate accumulates more and more, and 
when, the accumulation has reached a certain point, may be precipi- 
tated in a crystalline form in the joints and elsewhere, thereby deter- 
minating a fit of the gout." 

What is a fit of the gout ? While I have seen many cases, I can- 
not describe it as well as Bristowe. " The first attack of gout almost 
always comes on suddenly, with pain and swelling in the ball of one 
of the great toes, usually the right ; moreover, it occurs for the 



198 THE PRACTICE OF MEDICINE. 

most part early in the year, and almost without exception in the 
night-time. The patient goes to bed probably in his usual health, 
but awakes about two or three o'clock in the morning, with severe 
pain in the large joint of one of his big toes. The agony is some- 
times so intense that he does not move the affected limb ; he cannot 
bear the pressure of the bed-clothes, or even the slightest jar to his 
bed, or the slightest movement in his room ; his sufferings, too, are 
often aggravated by cramps and involuntary startings in the muscles 
of the legs ; he becomes restless and hot ; shivers, often has repeated 
rigors, and after tossing about for some hours, falls into a perspiration, 
and after a few hours falls asleep, from which he awakes refreshed 
and comparatively easy, but with the toe-joint swollen, tense, and 
vividly red, and with the superficial veins of the foot, and probably 
those extending up the leg, unusually distinct and full." 

These attacks occur on several successive nights, and then grad- 
ually diminish in severity, until in a week or ten days all the suffer- 
ing has passed away, but leaving the joint swollen, weak, and ten- 
der. Gout may attack any joint or any organ of the body, and irri- 
tate intensely the whole nervous system, and the mind. I have 
given the principal symptoms and pathology, for the reason that, 
while gout is chiefly a disease of England and the northern portion 
of Europe, it is becoming more common in America, especially in 
large cities, and in persons of English or German descent. When- 
ever I have treated cases of gout, I could nearly always get a his- 
tory of gouty ancestry. But the accumulation of wealth and enjoy- 
ment of leisure of the men of this country predisposes them to this 
disease, aside from heredity, and doubtless in time we shall become 
as gouty a nation as the English. It therefore behooves physicians 
to study the disease and all its multifarious manifestations carefully. 

Treatment, — What should be done during an inflammatory 
attack ? Most English and French physicians regard any measure 
to relieve the pain, general or local, as unadvisable. Others hold to 
the contrary. The affected parts should be kept at rest, if neces- 
sary by mechanical means. Hot or wet applications are not gener- 
ally agreeable, as in rheumatism, but cotton-wool or bran poultices 
sometimes give comfort. 

Ichthyol is said to have anodyne properties when applied to inflam- 
mations, and to have the power of penetrating through the skin, so 



CONSTITUTIONAL DISEASES. 199 

as to be able to act as an alterative, anodyne, and discutient, in 
cases of inflammatory enlargement or inflammatory pain. It is said 
that a fifty per cent ointment with vaseline, if spread over the affected 
joint, dusted with chalk, and cotton-wool over all, relieves the pain 
of gout in a short time, and that a continued use of it will shorten 
the duration, and bring about more rapid resolution. The imme- 
diate relief of the pain by medicines is problematical. Opiates are 
not advised, even by the old school. I have used phenacetine sev- 
eral times with benefit (three grains every hour), but in other cases 
no anodyne effect was noticeable from it. 

Aconite may be useful if we find all the symptoms correspond : 
as also may veratrum viride, if the arterial tension and temperature 
is very high. 

Colchicum was considered a specific in gout by nearly all English 
and Continental writers. They are now more cautious in its use 
than formerly. Once it was considered necessary to give ten to 
thirty minims every four hours until it purged. It did not give 
relief until five or six doses had been taken. Now it is taught that 
it should not be allowed to purge, as by its doing so the patient is 
often seriously injured. Smaller and more frequently-repeated doses 
are advised. I have found that in some cases one drachm of the lx 
mixed with four ounces of water, and a teaspoonful of this given 
every half-hour, gives relief in a few hours. Sometimes one drachm 
of the tincture of the seeds is required. Under its use the urine 
becomes more profuse, and slight sweating occurs. Good results have 
been obtained from colchicine in doses of one two-hundredth of a 
grain every hour. Even this small dose cannot be repeated for any 
length of time. The provings of apocynum andro. have symptoms 
very similar to an acute attack of gout. Several cases have been 
reported where its use in rheumatic gout of the feet has been fol- 
lowed by decided benefit. 

The radical treatment of gout must consist first of all in changing 
the patient's habits, if he uses alcohol, malt liquors, or rich food to 
excess. He should live on plain food, and exercise freely in the 
open air. The constant use of pure water containing lithia in some 
form is considered a sine qua non in all cases, but it will be of no 
benefit if the patient persists in the use of liquors and rich diet. 

Theoretically, the lithia salts and lithia water are lauded for 



200 THE PRACTICE OF MEDICINE. 

rheumatism, but they are not adapted to that disease. The benzo- 
ates of soda and lithium have been praised in gout, and I should 
expect the latter to be of benefit in acute cases ; in chronic cases, 
also, when the finger-joints are enlarged, I have seen good results 
from its long-continued use ; the effervescing salt, a teaspoonful 
three times a day, is the best form of administration. 

Arnica, internally and externally, has been beneficial. All the 
other remedies recommended in our text-books are useless. Hughes, 
who, as an Englishman, ought to know, says : " Gout has no home- 
opathic literature whatever. I have tried all the remedies which 
seemed indicated, or have been recommended : aconite, ledum, Pul- 
satilla, arnica, bryonia, and sabina, in the various dilutions, and 
have never been able to trace any decided effect to their use." He 
and other English homeopaths give colchicum in small doses, and 
declare it the only remedy in our materia medica of any real value. 
Dr. S. M. Cate, of Harvard, Mass., in a recent article on gout, one 
of the very few which have appeared in our literature, advises 
copious water-drinking. After giving the indications for twenty or 
more medicines on the supposition that they ought to be useful, he 
frankly says that the remedy he has used with the most satisfactory 
results is sulphurous acid. He uses the officinal solution, one teaspoon- 
ful in a tumbler of water, the whole taken at one dose, and " in 
sensitive persons," he gives one teaspoonful of a 1 to 9 solution 
at each dose. He says : "In acute cases I give a dose after each 
meal, or one once, in three hours till the pain is relieved, and then 
only once a day after meals. With this I give the indicated remedy, 
and cannot see that it interferes with its action ; and I have never 
seen any drug symptoms produced by it." He gives as an illustra- 
tion a case of chronic articular rheumatism, with all the joints 
enlarged, very much benefited in five months by the use of this acid, 
with calc. carb. He says the acid prevents the deposit of urate of 
soda in the joints, and that in chronic articular rheumatism, as well 
as in gout, it is present in the joints. No pathologist agrees with 
him that I am aware of. Longstreet (on Gout and Rheumatism), 
in his description of the morbid anatomy of the joints in chronic 
articular rheumatism, does not mention the presence of urate of 
soda. 

Charcot (" Diseases of Old Age ") says, when giving the morbid 



CONSTITUTIONAL DISEASES. 201 

anatomy of the joints : (1) "At once let us observe that the incrus- 
tation of cartilages is inseparable from articular gout." (2) " In a 
gouty patient the diseased joints alone present this lesion." (3) 
" This incrustation of urate of soda goes on independently of the par- 
oxysms or attacks." (4) " This lesion is peculiar to gout, and never 
occurs in articular rheumatism, whether acute or chronic." 



DISEASES OF THE THYEOID GLAND. 

This gland is the subject of several pathological conditions, 
namely : acute inflammation, congestion or engorgement, goitre, 
cancers, sarcoma, hydatid and simple cysts, and calculi. 



ACUTE INFLAMMATION. 

This condition may be idiopathic, although it is very rare ; metas- 
tatic, as in infectious fevers and pyaemia ; and traumatic. The swell- 
ing may cause dangerous symptoms by pressure on the trachaea, or 
prevent the swallowing of food. The treatment should be conducted 
the same as for mastitis, — by aconite, belladonna, phytolacca, and 
cold or hot compresses. If abscesses form they should be opened 
and disinfected by means of iodoform injections. 

CONGESTION OR ENGORGEMENT. 

This condition may be connected with the menstrual or pregnant 
states. If it comes on before the first menses, it is an indication for cal- 
carea carbonate, spongia, aurum bromide, or phytolacca. If the tur- 
gescence appears before each period, calcarea iodide, or aurum iodide, 
is indicated. If with the engorgement the menses are profuse and 
attended by sexual excitement, bromide of potassa and salix niger in 
large doses are indicated (ten grains of the former and thirty drops 
of the latter, three or four times a day, beginning a week before the 
expected menses). 

Dr. Scudder recommends iris versicolor for menstrual goitre, but 
does not explain why. Other eclectic writers assert its usefulness in 
recent goitres. When the engorgement becomes permanent, then 



202 THE PRACTICE OF MEDICINE. 

vascular goitre obtains. If the swelling is connected with cardiac 
excitement it is probably Basedow's disease (see " Exophthalmia") . 



GOITRE (Bronchocele). 

Definition, — A hypertrophy of the thyroid gland. It may be 
sporadic or endemic. Sporadic cases are common in all countries. 
Endemic cases occur principally in the mountains of Switzerland, 
and in certain parts of England, particularly in Derbyshire; in 
France, in the valley of the Rhone ; in New York, in the valley of 
the Mohawk; and in the Province of Quebec. Various theories 
have been advanced as to the nature and cause of goitre, but none is 
satisfactory. Defective sanitation, dampness, absence of sunlight, 
residence in marshy and uncultivated valleys or plains, are condi- 
tions under which it is most common. In high altitudes it is rarely 
seen. 

The ingredients of certain waters are supposed to cause goitre. 
It has been proven that lime does not cause it, although it may aggra- 
vate certain cases where calcification exists. It seems probable from 
the experiments of Maumene that the fluorides in drinking-water 
may be a cause. 

There are three distinct varieties of goitre : (1) parenchymous, 
in which the enlargement is general, and the follicles, usually newly- 
formed, contain a gelatinous material ; (2) vascular, due to dila- 
tion of the blood-vessels, without a new formation of glandular tis- 
sue ; (3) cystic goitre, when it is composed of large cysts, with or with- 
out calcified walls. The enlargement may be uniform, or affect but 
one lobe, or the isthmus alone. When the goitre is small it causes no 
physical discomfort, but is always a source of mortification to women. 
When large, the growth may press on the trachaea, causing dyspnoea, 
or if it extends beneath the sternum, compresses the veins. 

No work with which I am acquainted has brought out promi- 
nently the fact that there is a connection between vascular goitre 
and the reproductive organs. Nearly twenty years ago I published 
a series of cases in which the thyroid engorgement occurred before 
the first menstruation. On the appearance of the menses, the swell- 
ing subsided, to reappear every month, a week or so before the men- 
strual period. Since then I have occasionally seen brief notices of 



CONSTITUTIONAL DISEASES. 203 

~that phenomena. One writer mentions having seen cases of recur- 
ring goitre, which were probably of the kind I refer to. This 
variety rarely becomes permanent. I have also observed temporary 
vascular swelling of the thyroid during the last months of preg- 
nancy. 

Diagnosis. — A general hypertrophy of the thyroid may be a 
sarcoma, carcinoma, or an adenoma, instead of true bronchocele. A 
differential diagnosis should be made of the three varieties of goitre, 
because their treatment is essentially different. There is but little 
difficulty in ascertaining this, if the tactile sense is delicate, for the 
vascular, cystic, and parenchymous, are not at all alike to the touch. 

Treatment. — The regular or old-school treatment internally is 
with iodine alone. If this fails they have nothing left except local 
applications externally, or hypodermatic ally. Their most recent 
work on practice, that of Osier, mentions no treatment, but relegates 
the disease to the surgeon. 

Iodine is certainly useful in the parenchymous variety, but it 
should be given in appreciable doses. It is absurd to claim that 
iodine is homeopathic to goitre. Its primary action in large doses 
is to cause atrophy of all glandular structures. In small doses it 
perhaps stimulates some secretory glands, but there is no record of 
true hypertrophy of glandular structures from its use. The thyroid 
is not a secretory gland, and is therefore not influenced by the stim- 
ulating effect of iodine. To get the curative effect of iodine in 
appropriate cases, ten or fifteen drops of the ten per cent solution 
(lx) should be given before meals, when the stomach is empty. 
The same preparation should be applied externally on lint, and worn 
at night. With this treatment I have cured many cases. The one 
per cent solution may be strong enough when the patient is sensitive 
to its action. Painting the surface with the tincture of iodine is of 
no value. It has been proven that there is no absorption of iodine 
thus applied into the blood through the skin. Ointments of iodine, 
one to ten per cent, have been productive of benefit, but no prepar- 
ation of iodine can lessen the size of fibroid parenchymous hyper- 
trophy. 

Spongia, under the common name of " burnt sponge," has long 
maintained a reputation in the treatment of goitre. It has been sug- 
gested that all its virtues are due to the iodine which it contains. 



204 THE PRACTICE OF MEDICINE. 

But Preuss found calcined sponge to contain calcarea sulphate, na- 
trum mur., sodium iodide, magnesium bromide, calcarea carbonate, 
calcarea phosphate, and protoxide of iron. Our method of pre- 
paring sponge by roasting preserves all these constituents. It is a 
very complex drug, and as nearly all its ingredients may be indi- 
cated in goitrous affections, it is the most appropriate remedy we 
possess. I usually prescribe it in the lx trituration, giving five to 
ten grains after meals. Dr. Gilchrist believes he cured a case with 
the thirtieth, and that " large bilateral tumors, not sharply defined," 
indicate spongia. It may be useful in vascular goitre, when the 
heart is dilated, or in the early stage of cystic tumors, or when the 
parenchyma begins to enlarge by the formation of new glandular 
elements. After the parenchyma becomes indurated no drug is of 
benefit. 

Calcarea carbonate, prepared from egg-shells, is said to be super- 
ior to the pure chemical, just as calcarea phosphate, prepared from 
bones, is better than the drug prepared in the laboratory. It may 
be that inorganic substances gain a finer molecular condition when 
they have passed through the blood or fluids of a living animal, and 
are therefore better adapted to the requirements of a remedial agent. 
Hughes, Proll, and Ebstein recommend calcarea carbonate very 
highly. 

The salts of barium, especially the muriate and iodide, should be 
thoroughly tested in the various forms of goitre. 

Calcarea silico-fluoride — the compound salt which is supposed to 
cause goitre — has, according to Dr. Bellows, cured or benefited 
many cases. 

Fluoric acid was a few years ago highly praised by a few old- 
school writers, but it has not gained any decided reputation. In 
several cases under my care it had no perceptible effect. The solu- 
tion used was 1 in 1000, our 2x dilution, in doses of ten to twenty 
drops. 

Lapis alba, according to Grauvogl, has cured bronchocele. Silica 
and apis, according to Gilchrist, have cured cystic goitre. Extern- 
ally, the biniodide of mercury is used in India with great success, 
according to Quain. Three drachms of the drug are mixed with 
nine pounds of suet, and this ointment is rubbed into the swelling, 
which is exposed to the hot sun for several hours. The astounding 



CONSTITUTIONAL DISEASES. 205 

statement is made that 60,000 natives were treated by this method, 
and were nearly all cured. 

Eclectic physicians claim good results from ointments of uvedalia 
and phytolacca. I have never used the former, but have found the 
latter useful when, during engorgement of the gland, nodular lumps 
appear and there is some pain and tenderness, a similar condition to 
that of the mammae, in which it is so valuable. Hypodermatic in- 
jections of iodine, ergotin, carbolic acid, and osmic acid have been 
recommended. 

Iodine used in this manner may reduce the engorgement, but it 
may also cause the mammae and other glands to atrophy. It may so 
completely destroy the gland as to induce myxoedema. 

Ergotin and ergotinine are used under the belief that they will 
constrict the blood-vessels in cases of vascular goitre, but I do not 
see how this constriction is to be permanent. If they have cured 
vascular goitre there is no reason why ustilago and hydrastis or 
hydrastinine should not give the same results. 

Carbolic acid has been used in the public clinics in Chicago with 
undisputed success. Dr. E. O. Haven (" Weekly Medical Eeview ") 
injects twenty or thirty minims of a five per cent aqueous solution once 
or twice a week into the substance of the gland. The needle should 
be introduced from one-half inch to one inch into the gland, and the 
fluid then slowly injected. Little or no pain is experienced, but 
only a feeling of dizziness, which passes away in a few minutes. 
Usually this injection causes a contraction and a hardening of the 
connective tissue of the tumor, and a gradual lessening of the blood- 
supply, and in the course of eight or ten weeks a complete disap- 
pearance. No other treatment has shown such uniformly good results. 

Injections of osmic acid, one grain to two drachms of water, a 
syringe-full every other day for three weeks, is said to have cured 
goitre. 

The treatment of cystic goitre by injecting into the cavity iodo- 
form in glycerine (1 to 7) or 1 to 7 of ether with the same quantity 
of olive oil, has been successful ; ten to fifteen drops are injected 
every four to six days. In 150 cases no untoward result occurred, 
and nearly all improved. 

Dr. O'Keilly reports in the " Lancet " (April 2, 1892) success 
in reducing the size of a goitre estimated to weigh six pounds by the 



206 THE PRACTICE OF MEDICINE. 

injection of a solution of perchloride of mercury, alternating with 
one of iodine and one of permanganate of potash. When the tumor 
was reduced to about one-third its natural size and had become 
hard it was removed by operation. Dr. Auerbach advises intersti- 
tial injections of osmic acid, followed by massage for fifteen min- 
utes, while iodine is given internally. 

Dr. Kapper has reported marked diminution in the size of the 
enlargement in soft thyroid tumors, following injections of iodoform 
emulsion, according to Mosetig's plan. In the simple goitre which 
occurs in pregnancy, as noted by Lawson Tait, and others, there is 
usually a decrease in the size of the growth, or indeed it may wholly 
disappear after delivery ; but cases have been observed where this 
fortunate cure did not occur, and an instance has just been recorded 
by Dr. Jaffroy where there was an increase with succeeding preg- 
nancies, and finally all the symptoms of exophthalmos appeared. 
Dr. Bally's investigations of seventy-seven cases operated upon at 
Socin's clinic lead to the conclusion that intra-glandular enucleation 
is feasible in most cases, is not attended by dangerous hemorrhages, 
nor followed by paralysis of the vocal cords due to injury of the 
nerves ; while, as regards recurrence, it gives as favorable results as 
those offered by partial extirpation, and the operation is not followed 
by any disagreeable consequences, such as tetany or cachexia. For- 
tunately, goitre is not very common in the United States; but 
when, as was recently noted in the " Record," no less than 420,000 
persons suffer from the disease in thirty departments of France 
alone, the question of treatment becomes a very important one. 

In the presence of so much conflicting testimony concerning the 
merits of the various methods of treating goitre, one naturally hesi- 
tates in making choice. To be sure, we must take into consideration 
whether the growth be parenchymatous or cystic, simple or exoph- 
thalmic, recent or of long-standing. The plan of treatment then to be 
adopted will be either by internal remedies, external applications, 
interstitial injections, electricity, or operation ; possibly some of these 
methods may be combined. To instance two widely separate meth- 
ods, geographical as well as therapeutic : Dr. Upendra Nath Sen 
writes in the "Indian Medical Gazette" (March, 1892), that at 
Mymensing it is an every-day occurrence to treat half-a-dozen cases, 
since half the population is affected. This great prevalence he attrib- 



CONSTITUTIONAL DISEASES. 207 

utes to the water of the Jamuna River. His treatment consists in the 
outward application of biniodide of mercury ointment, and the secret 
of success lies in the fact that "the patient must be kept facing 
toward the east sun at least two hours, when the ointment will be 
absorbed." The cure is more rapid if the tincture of iron be given 
internally at the same time. 

Dr. Cline, of Woodstock, Va., states that he has " been surprised 
just twenty-two times in the cure of goitre." Tincture of iodine is 
used externally, while corydalis and iodide of potassium are given by 
the mouth. 



MYXCEDEMA. 

Definition. — A dropsical condition of the sub-cutaneous tissues, 
brought about by the congenital absence of the thyroid gland, or its 
surgical removal. There are three forms of this disease, as follows : 

(1) Congenital. — In which there is absence of the thyroid, and 
the child is a dwarf, having a thick neck, short arms and legs, and 
prominent abdomen. The face is large, lips thick, and the tongue 
is usually so big that it protudes. 

(2) Myxoedema proper. — This is more common in England than 
in this country. It occurs generally in women ; it may be trans- 
mitted through the mother to several members of a family. It may 
begin with exophthalmic goitre. The characteristic symptoms are a 
general increase of the bulk of the body ; a firm elastic swelling of 
the skin, which does not pit on pressure. The skin is dry and rough, 
the face loses its expression, and the hair loses its nutrition. The 
features become coarser and repulsive, the lips and nose become 
thick, the mouth enlarged, and the mind becomes affected with slow- 
ness of thought and movement. The memory is defective ; patients 
become irritable and suspicious, and have delusions and hallucina- 
tions. . The gait is heavy and slow. The temperature is below nor- 
mal. Hemorrhage, albuminuria, and glycosuria may occur. The 
thyroid gland is diminished in size, and may become completely 
atrophied and converted into a fibrous mass. The course of the dis- 
ease is slow, and may extend over ten or fifteen years. 

(3) Operative myxoedema. — This is caused by surgical removal 
of the thyroid. Dr. Horseley removed the thyroid gland of monkeys, 



208 THE PRACTICE OF MEDICINE. 

and in every case it was followed by a condition similar to that of 
myxoedema, often attended with spasms or tetanoid contractions and 
apathy, followed by coma. A curious fact was developed during 
these experiments. If the monkeys were kept warm, myxoedema 
was arrested, and instead developed a condition which closely re- 
sembled critinism. The same condition may follow the operation in 
man. When the gland is removed, if a small piece is left the myxoe- 
dema does not obtain. 

Treatment. — No medicine has any favorable effect on this con- 
dition, but, as the patients are worse in cold and better in warm 
weather, their condition can be greatly ameliorated by sending 
them to warm climates. I have seen but two cases ; that was many, 
years ago, before its real nature was known. If the thyroid has to 
be removed, a small portion should be left in situ. When it has been 
completely extirpated, a small piece of healthy gland from an animal 
can be inserted somewhere beneath the skin. In Merklin's case, 
where a woman of forty-one years greatly improved, the graft was 
one of the lobes of the thyroid of a sheep. It was transplanted under 
the skin of the sub-mammary region. 

" A case of myxoedema, in London," says the " Medical Record, 
" is now uuder a curious treatment. The patient is a woman aged 
forty, who for nearly three years has been under treatment for myx- 
oedema. In every respect it is an extremely typical case ; persist- 
ently subnormal temperature, general swelling of the integuments, 
dryness of the skin, partial baldness, clumsiness of movement, slow- 
ness and thickness of speech, etc. The patient was admitted to the 
hospital in July, under the care of Dr. Hector Mackenzie, for the third 
time, in order to be treated by hypodermic injections of thyroid juice. 
In consequence of the difficulty experienced in obtaining the latter, 
Dr. Mackenzie was induced to try the effect of feeding the patient 
on fresh thyroid glands. The result has been a very striking improve- 
ment. The myxedematous swelling has entirely disappeared, the 
temperature has become steadily normal, the skin moist, and the 
speech natural. The patient asserts that she feels perfectly well." 

A writer in the London " Lancet " says : 

" The belief in the importance to the animal economy of the 
presence in the normal state of such bodies as the thyroid, supra- 
renal capsules, etc., is steadily gaining ground in this centre of med- 



CONSTITUTIONAL DISEASES. 209 

ical activity. That organs unprovided with excretory ducts do form 
some product which is reabsorbed into the blood is proved by the 
disastrous effects following their removal. The development of 
myxcedema in persons whose bronchocelic thyroids have been removed 
is a phenomenon familiar to all practitioners of medicine. It is 
further proved by the experiments of Hedon, of Montepellier, already 
communicated by me to the i Lancet,' that the continued vitality 
of a grafted portion of the pancreas insures the animal against dia- 
betes, even though the intra-abdominal portion be excised. That 
condition is, on the contrary, induced by the total ablation of the 
normal but evicted pancreas, and also by the destruction of the 
grafts, the intra-abdominal portion being left in situ. As regards 
myxcedema, Professor Bouchard reports two cases recently treated 
by him at the Charite Hospital by means of injections of thyroid 
juice. Both patients were females, and the improvement was, in 
each instance, extraordinarily rapid." 



SEPTICEMIA. 

« 
Definition. — Septicaemia is a general febrile affection, without 

foci of suppuration. The organisms producing this condition are 

generally those of suppuration. Senn says it assumes three forms : 

(1) Fermentation fever. — Aseptic fever or after-fever, the sim- 
plest of all wound complications. It is the febrile process which is 
produced after transfusion or the injection of pepsin into the blood. 
This fever may follow any injury or operation, particularly if there 
has been necrosis of the superficial tissues by the solution used in 
the dressing. It may follow the extravasation of blood, particularly 
when under pressure or tension. The fever, which appears a few 
hours after the injury or operation, is not preceded by a chill. It 
usually reaches its height rapidly, sometimes to 103° or 104° F. 
There is not much general disturbance, and the fever usually sub- 
sides in from one to three days. 

(2) Sapraernia. — This is a septic intoxication caused by the 
ptomaines produced in wounds by the putrefactive bacteria. In the 
growth of these organisms chemical poisons (toxins) are produced, 
and the symptoms are caused by the absorption of these toxins. 



210 THE PRACTICE OF MEDICINE. 

The symptoms vary with the quantity absorbed. In about twenty- 
four hours after the injury or operation, a chill is observed ; after 
which the fever rises rapidly, reaching 103° or 104° F., with quick 
pulse, great prostration, headache, restlessness, and delirium. The 
tongue is dry and glazed, and there may be severe gastric irritation 
and all the phenomena of severe infection. 

(3) Progressive septicaemia. — In this form, the septic poisoning 
is not the result of the bacteria of putrefaction, but organisms enter 
the blood from some local septic focus, and these form ptomaines. 
Pus microbes are the most frequent cause of this form of septi- 
caemia. We find this form in puerperal fever and dissection 
wounds, and the course of the infection may be traced along the 
lymphatics. The initial chill may occur within twenty-four hours, 
or not until the third or fourth day. The fever is moderate at first, 
but gradually rises, and is marked by daily remissions and even 
intermissions. The pulse is small and soft, and may reach 120 or 
higher. The tongue is red at the margin, and the dorsum dry and 
dark. There may be delirium or marked mental prostration and 
apathy. Pallor of the face, with a yellow hue, appears after a time. 
Capillary hemorrhages are not uncommon. Death may occur within 
twenty-four hours in severe cases ; life is rarely prolonged more than 
a week. 



PYEMIA. 

Definition. — A condition characterized by recurring chills and 
an intermitting fever, with the formation of abscesses in various 
parts, resulting from the contamination of the blood by products 
arising from a foci wherein are the bacteria of suppuration. It may 
be caused by thrombosis and embolism. According to Klebs, Koch, 
and others, micro-organisms play an important role in this disease. 
The pus microbes and their toxins cause nearly all the symptoms of 
this condition. The entrance of these organisms in small numbers 
into the blood does not necessarily cause pyaemia. A thrombus 
which does not come from an infected source will not cause it. One 
form of pyaemia is caused by suppurative endocarditis, primary or 
secondary. 

The diagnosis of pyaemia from septicaemia is often difficult. It 



CONSTITUTIONAL DISEASES. 211 

may be mistaken for osteo-myelitis, or the septic infection which fol- 
lows gonorrhoea and scarlatina, typhoid fever, or tuberculosis. Dr. 
Helmuth says, "In pyaemia the contamination of the blood takes 
place through the blood-vessels ; in septicaemia, through the lym- 
phatics. The chills in pyaemia are recurrent or intermittent ; in 
septicaemia there is but one slight chill. There is jaundice in 
pyaemia; paleness in septicaemia." The chills, fever, perspiration, 
and jaundice may simulate intermittent malarial fever. 

Treatment. — The radical treatment of these conditions belongs to 
the domain of surgery. The most that medicine can do is to modify 
and palliate the symptoms. Internal antiseptics are of no practical 
value. We cannot safely inject into the blood a sufficient quantity 
of any antiseptic to change its condition by destroying the organisms 
or their resultant toxins. Quinine has no curative power ; it neither 
supports the patient nor breaks up the febrile paroxysms. Its only 
value is a diagnostic one. If we are in doubt whether the fever is 
malarial or pyaemic, quinine may be given. If it arrests the par- 
oxysms then they are malarial. Osier says, " The practitioner may 
take it as a safe rule that an intermittent fever which resists qui- 
nine is not malaria." « ' , 

Dr. Pomeroy, in his article on Pyaemia in Arndt's " Practice," 
recommends quinine " when there is a tendency to periodicity of the 
symptoms." This is misleading. It may be of some value when 
its characteristic symptoms are present, namely, profuse perspiration 
during sleep, riDging in the ears, deafness, etc., but even in such 
cases I prefer the tincture of cinchona. Nor is it of any use to give 
veratrum viride, aconite, or gelsemium to control the temperature, 
for they will not do it, unless massive doses are given, and then they 
act like antipyrin and other chemical antipyretics ; they injure the 
integrity of the system, rather than modify the ravages of the poisons 
in the blood. 

The surgeon should evacuate the pus wherever found, and render 
the cavity aseptic. The obstetrician should wash out the uterus 
with boric acid, benzo-naphthol, or eucalyptol water, and if there are 
foreign infective matters adhering, remove them with the curette. 

Eucalyptus and baptisia internally, in the mother tincture or lx, 
act better than any other drug. The diet should be sustaining and 
nourishing; milk, koumiss, buttermilk, egg-nog, beef extract, and 



212 THE PRACTICE OF MEDICINE. 

broth, should be given and injected per the rectum. The drinks 
should be red wine, lemonade, or water slightly acidulated with any 
of the mineral acids ; and the body frequently sponged with euca- 
lyptus water, or thymol-hydrastis, diluted. 



PURPURA. 

Definition. — A condition of the blood and capillary vessels 
which allows extravasation into the skin and sub-cutaneous tissue. 
It can hardly be called a disease, but a symptom appertaining to 
many diseases. Purpuric spots vary in size from a point to an area 
of an inch or more in diameter. When small and like pin-points 
they are called petechiae ; when large they are known as ecchymoses. 
At first generally bright-red in color, they become darker, and 
gradually fade to brownish or greenish-yellow stains. They do not 
disappear on pressure. It is not easy to make a satisfactory classi- 
fication of purpura. The following is probably as good a division 
as can be made : 

(1) Purpura traumatica. — When it arises from a blow or strain, 
or the efforts made during whooping-cough and straining at stool. 
In a case of constipation under my care, in a man of thirty, the spas- 
modic straining was so violent that every stool was followed by 
petechial spots all over the face, neck, and chest. 

(2) Symptomatic or infectious. — When it occurs in pyaemia, 
septicaemia, typhus-fever, measles, scarlet-fever, and malignant en- 
docarditis. 

(3) Cachectic. — When it develops during scurvy, cancer, tuber- 
culosis, Bright's disease, and in senility. In these cases the spots 
are usually confined to the extremities — the lower legs, and the 
wrists and hands. 

(4) Neurotic. — When it occurs during locomotor ataxia, and 
follows the lightning-like pains. It also occurs during cerebro- 
spinal meningitis, myelitis, and sometimes attends violent neuralgia. 
There is an hysterical form called stigmata, when bleeding points 
appear on the skin, as in some nuns in whom the points appear in 
the hands and feet at the points where the nails were supposed to 
have been driven when Christ was suspended to the cross. 



CONSTITUTIONAL DISEASES. 213 

(5) Toxic. — When it is due to the action of drugs, such as phos- 
phorus, secale, ustilago, copaiva, quinine, belladonna, rhus, turpen- 
tine, sulphuric acid, erigeron, arnica, hamamelis, arsenic, chloral, 
iodine and the iodides, bromine and the bromides, ledum, bellis, and 
bryonia. The virus of snakes (crotalus, lachesis, naja, and others), 
the bites of fleas, mosquitoes, and other insects, will in some indi- 
viduals cause petechias. The purpura occurring in malignant jaun- 
dice comes under this head. 

(6) Arthritic or rheumatic. — There are three varieties of this 
purpura. One called purpura simplex, seen most commonly in chil- 
dren, in whom, with or without pain in the joints, purple spots appear 
on the legs, generally the shins, rarely upon the trunk. It may be 
attended with loss of appetite, diarrhoea, and anaemia. It lasts a 
week or ten days. 

Another form, described by Schonlein, is characterized by a mul- 
tiple arthritis. The eruption varies in appearance ; it may be pur- 
puric, urticariaus, or erythematous. It is most common between 
the ages of twenty and thirty. It sets in with a sore throat, fever 
from 101° to 104°, and pains in the limbs and joints. There is some 
cutaneous oedema. The wheals, purpuric spots, and nodosities may 
all appear together. The nodes are very painful and sensitive. I 
once saw this affection attend a rheumatic endocarditis, and I have 
several times seen it appear during a rheumatic fever. 

Osier describes an arthritic purpura which presents marked gas- 
tro intestinal and renal symptoms. It is not uncommon, and most 
frequently occurs in children. It sets in with pain and swelling 
of the joints. Purpura and urticaria develop about them, and the 
case looks like one of rheumatic purpura. Soon other symptoms 
develop ; the child has attacks of severe vomiting and diarrhoea, 
with true gastro-intestinal crises, particularly at night. There may 
be hemorrhage from the bowels, and renal symptoms, such as 
albumin, tube casts, blood, and all the symptoms of hemorrhagic 
nephritis. 

Purpura hemorrhagica is a form of very severe purpura with 
hemorrhage from the mucous membranes. This is sometimes called 
morbus maculosus. It occurs in young and delicate persons. After 
a few days of weakness and prostration, purpuric spots appear on 
the skin, and rapidly increase in numbers and size. Bleeding from 



214 THE PRACTICE OF MEDICINE. 

the mucous surface sets in, and the epistaxis, haematuria, and haem- 
optysis may cause profound anaemia. Death may take place from 
loss of blood, or from hemorrhage into the brain. There are instances 
of this disease of such malignancy that death has occurred in twenty- 
four hours. In the diagnosis of this variety it is important to 
exclude scurvy. In purpura, however, there is no swelling of the 
gums. 

Treatment. — The treatment of each form must be based on the 
pathological condition and the peculiar symptoms shown by the 
patient. We must first, however, ascertain if the environment of 
the patient has anything to do in causing the diseases. If we find 
the residence damp, cold, malarial, or if the house is infected with 
sewer-gas, the patient should be removed, if possible, to better 
quarters. Without giving the general and special characteristic 
indications for all the medicines useful, as has been done so admir- 
ably by Dr. George W. Winterburn in his " Monograph on Pur- 
pura" (published in 1886), I will point out the remedies for the 
various forms. 

In the symptomatic or infectious : Baptisia, arsenic, rhus, ailan- 
tus, lachesis, crotalus, turpentine, phosphorus, arnica, sulphuric acid, 
bryonia, and eucalyptus. 

In the cachectic : Secale, cinchona, ferrum muriaticum, arsenic, 
arseniate of iron, arseniate of quinine, mercurius corrosivus, and 
arsenite of copper. 

In the neurotic : Secale, ustilago, phosphorus, arnica, strychnia, 
arsenic, and the arseniates of quinine, strychnia and copper, cicuta, 
apis, chloral, belladonna, hyoscyamus, antipyrin, and phenacetine. 

In the arthritic variety I have found arnica and ledum the most 
successful medicines. They correspond closely to the symptoms and 
conditions which prevail in nearly all cases. I treated one case suc- 
cessfully with manaca (francisca uniflora), when the patient had the 
sensation of an iron band around the head, with intense soreness of 
the joints, and erythematous nodes. Salicylate of soda in small 
doses, one or two grains every two hours, has been useful in several 
cases. Rhus and bryonia may be of value in cases which seem to 
call for their use, but I have rarely found them so. In the purpura 
simplex of children, I find phenacetine, ledum, apis, and arnica most 



CONSTITUTIONAL DISEASES. 215 

useful. Osier makes the remarkable statement that " in the simple 
purpura of children, or that associated with slight articular trouble, 
arsenic in full doses should be given. No good is obtained from 
small doses, but the Fowler's solution should be prescribed freely 
until its physiological effects are obtained." Arsenic is homeopathic 
to purpura, but its purpuric symptoms indicate it only in the cachec- 
tic, infectious, and hemorrhagic varieties. Winterburn records no 
cases of the arthritic variety cured by it. I do not doubt Osier's 
experience, but I cannot imagine why arsenic acts so favorably in 
such cases and in such toxic doses. On the other hand, I can see 
how it may act curatively in small doses in the arthritic purpura in 
children with gastro-intestinal and renal complications, because it 
seems perfectly homeopathic to that group of symptoms. I am cer- 
tain, however, that in this form arsenic could not be safely pushed 
until its physiological effects appeared. The 3x or 6x will doubtless 
be strong enough. 

Purpura hemorrhagica should be treated by phosphorus, secale, 
carbo. veg., turpentine, erigeron, thaspi, sulphuric acid, hamamelis, 
hydrastis, chloral, and the serpent poisons. 

Turpentine and sulphuric acid were useful in the four cases that I 
have treated, — all the patients recovered. Turpentine was prescribed 
in the lx, ten drops every two hours ; dilute sulphuric acid in doses 
of five drops every two hours. The diet during the treatment should 
be very sustaining, — buttermilk, koumiss, beef extracts, lemonade 
with white of egg^ port wine jelly, malted milk, orange and lemon 
juice, and clam broth ; alcohol should be avoided, as should all malt 
liquors. 

There is doubtless some value in topical applications to the sur- 
face when the purpuric spots bleed. Arnica and hamamelis, a ten or 
twenty per cent solution, applied constantly, will in my experience 
prevent the oozing hemorrhage. Hydrastis, owing to its specific 
influence over the coats of the arterioles and capillary vessels, should 
make a good local application — a ten per cent solution is of suffi- 
cient strength. The distilled extracts of arnica and hamamelis can 
be used. I have never tried the white hydrastis solution, but believe 
it will be useful in this disease. Antipyrin is recommended as a 
topical application. 



216 THE PRACTICE OF MEDICINE. 



HEMOPHILIA. 

Definition. — A constitutional disease, generally hereditary, with 
a tendency to uncontrollable bleeding, which may occur spontan- 
eously or from slight wounds. Those who desire to consult copious 
authorities are referred to the writings of Buel, Hay, Coates, Legg, 
and Grandidier. They assert the family nature of the disease, 
but admit that the fault may be acquired, though they say " noth- 
ing is known of the conditions under which the disease may arise 
in healthy stock." Some instances of the hereditary transmission 
of the disease are remarkable. It has been known to occur in the 
sixth and seventh generations. The usual mode of transmission is 
through the mother, who is not herself a " bleeder," but the daughter 
of one. Males are more often affected then females, the proportion 
being as high as 11 to 1 or 13 to 1. The tendency usually appears 
as early as the first two years of life. Condition in life does not 
modify the tendency ; the families of " bleeders " are large, they look 
healthy, and have fine soft skins. No special morbid anatomy has 
been found that throws any light on the nature of the disease ; there 
must be some peculiar undiscovered frailty of the blood-vessels, or 
some peculiarity in the constitution of the blood, which prevents the 
normal thrombus-formation in the wound. The victims may bleed 
externally and internally ; spontaneously, or from some injury. The 
following is in the order of frequency of the hemorrhages as to loca- 
tion : nose, mouth, stomach, bowels, urethra, lungs, tongue, vulva, 
ear, navel, fingers. The bleeding is a capillary oozing, and may last 
for hours or days. Epistaxis may prove fatal in twenty-four hours ; 
the blood seems to lose the power of coagulation. The joints may 
be affected in a singular manner ; they are attacked by pain and 
swelling, and simulate rheumatism, but this condition is due to hem- 
orrhage into the joint. 

Diagnosis. — Haemophilia should not be confounded with pur- 
pura. One uncontrollable hemorrhage in a person should not be 
pronounced haemophilia ; it is only when repeated intractable hem- 
orrhages occur, and a family tendency is traceable. 

Prognosis. — Death rarely occurs from a first bleeding. The 
younger the patient, the worse the prognosis. The longer he sur- 



CONSTITUTIONAL DISEASES. 217 

vives the repeated attacks, the better his chance of outliving the 
tendency. 

Treatment. — The most radical treatment would be forbidding 
the daughters to marry, as it is through them the disease is trans- 
mitted. The boys of a bleeding family should be guarded against 
injury of all kinds, even in early infancy. ^Vhen an injury has been 
received, absolute rest should be enforced, and compression with lint 
saturated with hamamelis, hydrastis, arnica, aromatic vinegar, or a 
solution of muriate of baryta. The lint should not be allowed to 
get dry, and when removed it should be done with great care. Inter- 
nally, ergot is reported to have cured several cases ; also the per- 
chloride of iron ( u thirty drops every two hours," Dr. Legg). 

I have treated a few cases, with no deaths. Besides the com- 
presses mentioned, I gave internally lachesis sixth, phosphorus sixth, 
and hamamelis mother tincture (twenty drops every two hours in one 
case.) Turpentine, erigeron, thaspi, crotalus, ustilago, trillium, and 
millefolium may be tried, but I cannot personally recommend them. 

In dangerous hemorrhages during the menses, as reported by 
Townsend and Yickery ("Boston Medical and Surgical Journal"), 
I should advise packing the vagina with styptic cotton or injecting 
compound tincture of iodine into the womb. A case of bleeding (into 
the bladder) from the right ureter is reported by Senator, of Berlin. 
It was so persistent that he removed the right kidney, " after which 
the bleeding ceased, and has not returned." 



SCURVY (Scorbutus). 

Definition. — Scurvy is a constitutional disease, the chief charac- 
teristics being great debility, with anaemia, a spongy condition of the 
gums, and a tendency to hemorrhage. 

This disease develops whenever individuals have subsisted for 
prolonged periods upon a diet in which fresh vegetables or their sub- 
stitutes are lacking. It is now a very rare disease, owing to the 
modern methods of canning and preserving vegetables, so that ocean 
vessels and armies are now freely supplied with them. Other factors 
besides the absence of fresh vegetables, with their malic, citric, and 
lactic acids, may tend to produce this disease. Physical and moral 



218 THE PRACTICE OF MEDICINE. 

influences, such as over-crowding, dwelling in cold damp quarters, 
prolonged fatigue under depressing influences, as during the retreat 
of an army, and the profound mental depression of prisoners. 
Homesickness may cause scurvy. 

Symptoms. — Early symptoms are loss in weight, weakness, and 
pallor. The gums become swollen and bleed easily, and sometimes 
present a fungous appearance. The teeth may become loose and 
fall out. The breath is very offensive. The salivary glands may 
be enlarged. The skin becomes dry and rough, and ecchymoses soon 
appear, first on the legs, then on the arms and trunk. In severe 
cases there may be effusion between the periosteum and bone, form- 
ing irregular nodes, which in bad cases break down and become 
ulcers. The slightest bruise or scratch causes hemorrhage. (Edema 
about the ankles occurs. Epistaxis is common, and other hemor- 
rhages may occur. The heart's action is feeble and irregular ; the 
temperature higher than normal. 

Treatment. — Medicines are rarely required, except when mental 
or moral causes help to bring on the disease. The free use of lemon 
and lime juice, or eating freely of any acid fruit, with plenty of fresh 
vegetables, rarely fails to effect a cure. If the improvement is slow, 
however, it may be aided by the use of mercurius, nitric acid, aurum 
muriate, phytolacca, corydalis, and other remedies having homeo- 
pathic relation to the pathological condition. The mental depression 
may be benefited by aurum, ignatia, anacardium, cimicifuga, and 
others. When the stomach is very sensitive, scraped fresh raw meat, 
with milk, is beneficial. As the digestion becomes stronger, water- 
cresses, lettuce, greens, and potatoes are permitted. Mouth-washes 
of a very weak solution of carbolic acid, boracic acid, or permanga- 
nate of potash can be used to advantage. Sulphuric acid, thaspi, 
and turpentine are the chief remedies for the various hemorrhages. 



INFANTILE SCURVY. 

This form of scurvy is more common than is supposed, and is often 
not recognized until too late. It occurs in infants and young chil- 
dren fed upon improper food. It develops a cachexia, which has 
been mistaken for acute rickets, but which Cheadle and Barlow have 
shown to be a form of scurvy. The most striking cases develop in 



CONSTITUTIONAL DISEASES. 219 

infants reared on artificial food prepared with water, though the dis- 
ease has occurred when these foods were prepared with milk. 
Rickets strongly predispose to the condition. The cases may occur 
in infants, or in children up to the age of ten. Barlow thus sum- 
marizes the chief features : 

" (1) Predominance of lower limb affections : (a) immobility, 
going on to pseudo-paralysis ; (b) skin shiny and tense, but seldom 
pitting, and not characterized by undue local heat ; (c) on subsi- 
dence, revealing a deep thickening of the shaft ; (d) liability to frac- 
ture near the epiphyses. (2) Swelling of the gums varying from 
definite sponginess down to a vanishing-point of minute transient 
ecchymoses ; these constitute the chief diagnostic differentia between 
infantile scurvy and rickets, properly so-called ; but to them must 
be added, as the most important diagnostic of all : (3) Definite and 
rapid amelioration by antiscorbutic regimen." 

According to Gee, haematuria may be the only sign of scurvy in 
children. Dr. Mayo, in " Merck's Bulletin," relates the following 
typical case : 

"I was called to see Dr. S.'s child, twenty months old, on July 
12, 1891. He had not been sick, but puny since January before ; 
his skin had a dark unhealthy appearance, as if slight venous con- 
gestion had set in. About the 4th or 5th of July he commenced 
complaining of pain in the right thigh, supposed to have been hurt 
by the nurse ; he could not use that leg, and cried if it was touched ; 
gums much swollen, and of the color of dark venous blood. Wherever 
he was bitten by an insect, or pricked with a pin, the puncture turned 
black instead of red. Had ' cut ' sixteen teeth without much trou- 
ble ; on examination of the mouth, only three of them were visible, 
the rest covered by the swelling. Had never had trouble, of any con- 
sequence, with the bowels. Had been under medical surveillance 
since January, but had during that time retrograded. The parents' 
anxiety about the child's leg made them send for me. Upon exam- 
ining the mouth, I passed a lancet through the swollen gums, and 
could feel no more resistance to the lancet than would have been 
felt in passing through a blood-clot, though there was a visible, 
organized membrane over the dark venous blood. Pulse and tem- 
perature normal ; thought the latter a little below the natural stand- 
ard, but was not certain, as the restlessness of the child made the 



220 THE PRACTICE OF MEDICINE. 

application of my thermometer quite difficult. I examined the thigh, 
but could find no evidence of injury or disease, except the pain. 
The father thought there might be dislocation of the hip joint ; but, 
as there was no evidence of it, I denied it. The diagnosis was to 
my mind obscure, but I was inclined to think it purpura. I ordered 
an astringent mouth-wash, and turpentine internally. After a night's 
reflection and the examination of authorities on children, I con- 
cluded it was not purpura, but must be scurvy (with which I had 
before been familiar, in California, 1849-50). There was no such 
title in any work on children in my possession, and as children in 
our country are usually fed on milk (an antiscorbutic), I could not 
account for my diagnosis. Upon inquiry, next morning, I found this 
child had been reared exclusively on Reed & Carnrick's 'soluble 
food.' I gave him no medicine, ordered fruits and lemonade, salad 
made of scraped raw Irish potatoes, seasoned with lemon juice and 
sugar ; no treatment to the leg ; mouth-wash continued ; and milk 
to be substituted for the Reed & Carnrick's ' soluble food.' (The 
last direction was not carried out to the letter, as the child fretted 
for its accustomed food ; the remainder of the prescription was 
strictly obeyed.) The child improved in health and flesh imme- 
diately, and in three weeks was running about, free from all pain, 
with only a little sponginess of the gums, which in two months were 
perfectly well, with teeth healthy, firm, and white. He had not 
taken a dose of medicine, and continues healthy up to date." 

Dr. James McManus (in the " Medical Record ") recently 
reported a case of scurvy in a child of twenty months which had been 
fed on condensed milk alone. It had a dark, grumous diarrhoea, 
swollen and bleeding gums, and ecchymoses on the legs. The diet 
was changed to fresh cow's-milk, beef, orange juice, and lemonade. 
All the scorbutic symptoms disappeared in a week. 

Dr. Carr reports in the same journal a case, which shows the 

paralytic symptoms which may occur : " V. R. K , female, aged 

fifteen months ; first child. The baby was nursed until she was six 
weeks of age, when she was weaned, and fed condensed milk for six 
weeks longer, after which Mellin's food was used. This seemed to 
agree with her, though at first she did not like it, and the condensed 
milk was given in its place from time to time. The first lower incis- 
ors showed at eight months ; the baby stood and walked with assist- 



CONSTITUTIONAL DISEASES. 221 

ance two weeks later. During September, 1891, bowel trouble 
developed, which continued for some months and weakened the baby- 
very much. The diet was kept the same. In November she refused 
to stand, and when placed on her feet would fall. The following 
month, December, she became irritable, fretful, and did not sleep 
well. She appeared to have fever. Her legs were tender and sore, 
and she kept her thighs drawn up on her abdomen. When her 
clothing was changed she would scream as if in pain. After this 
condition had lasted about six weeks, the baby extended her legs, 
but did not seem able to use them, although they were not so tender. 
On the legs were streaks and spots which looked like bruises, and in 
the centre of some of the purpuric patches were reddish dots that 
resembled pin-pricks. The movements from the bowels were as fre- 
quent as sixteen a day, and varied greatly in appearance. Some- 
times the stools were green, then were black, or dark green, and 
again were natural in color. Often they contained a large quantity 
of mucus and were streaked with blood. May 18, 1892, I first saw 
the baby, and my attention was called to the weakness of her legs. 
I found her to be a plump infant, with very little muscular strength, 
and a great deal of tenderness all over the body, and especially of 
the thighs. She evidently experienced pain when she was handled, 
and began to cry before she was touched. The thighs had a swollen 
appearance, and were sausage-shaped, with some of the swelling 
below the knees. The lower thirds of the femurs felt thickened, 
and the thighs were exquisitely tender. There was not any heat in 
the parts. The sensation was good, but the muscular power was so 
weakened that the extremities could not be drawn up. There was 
no staining or discolor ations. The abdomen was soft and distended. 
The liver and spleen were not enlarged. As the baby cried, the 
gums were seen to be swollen and bleeding, with the teeth half-hid- 
den by the soft alveolar tissue. The tongue was covered with a dirty 
yellowish-brown coating, and with blood from the gums. The ante- 
rior fontanelle was as open as is usually observed at fifteen months. 
Head moist ; no craniotabes ; no marked rachitic changes in epi- 
physes, or along the edges of the flat bones. Examination of the 
chest showed the presence of mucous rales, some of which at the 
bases of the lungs were rather fine ; but there was no dulness. The 
temperature in the rectum was almost 105° F. The mother was 



222 THE PRACTICE OF MEDICINE. 

ordered to stop the condensed milk, and to give the baby fresh milk, 
beef juice, and the juice of an orange every day. No medicine except 
a placebo was prescribed. After the visit of May 18 the baby had 
the measles, accompanied by a severe attack of bronchitis. The high 
temperature noted was no doubt due to the onset of the acute dis- 
ease. Under the change in diet the baby had made rapid improve- 
ment, and, although ill with the measles, the gums were better in 
three days, and normal by the end of a week. June 21 was recorded : 
4 Baby's general condition good. Some perspiration of the head and 
body. The muscles are not very strong, and there is a slight curva- 
ture of the spine, due to the want of muscular support. There is no 
tenderness of the thighs. Gums are all right. The stools contain 
a little mucus.' June 29, the mother sends word that the baby's 
bowels are much improved, and that she is gaining in strength and 
weight. She uses her legs and feet better than she had ever done 
before the illness. The history of the case shows that there were not 
any puzzling symptoms, and the diagnosis was readily made. I wish 
to call attention to the two features that were most prominent, and 
which should be looked for in all cases of the same character. These 
symptoms were the tumefied bleeding gums, which almost covered 
the teeth, and the tender, swollen thighs." 

To these cases I will add one of my own, which presented some 
peculiar features. The infant was six months old, was apparently 
well-nourished, looked fat, but the flesh was soft and flabby, the 
fontanelle very open. The mother called my attention to the gums, 
which were a livid red, soft, spongy, and bleeding. This was soon 
after the child had recovered from an attack of la grippe. There 
was excessive tenderness of the lower limbs, with pain on movement, 
and some paralysis of the abductor muscles of the feet. The food of 
the child had been for five months principally granum gruel, mixed 
with equal parts of milk. 

It did not seem to me that the food was deficient in proper ma- 
terials, but there were the unmistakable symptoms of scurvy. I gave 
no medicine, but ordered the diet changed to fresh milk alone, mixed 
with egg albumin, and ordered that the child be fed the juice of one 
acid orange three times a day. Under this regimen the scorbutic 
symptoms soon disappeared. 



CONSTITUTIONAL DISEASES. 223 



OSTEOMALACIA. 

" This lesion consists in the softening of fully-formed hard bone- 
tissue by the removal of its inorganic salts. It is to be clearly distin- 
guished from rickets, the lesions of which are due to a faulty devel- 
opment of bone, although in certain external characteristics the two 
diseases sometimes present considerable similarity. Osteomalacia 
usually occurs in adults, most frequently in females during pregnancy 
and after parturition ; more rarely it occurs in males, and in females 
unassociated with the above conditions. Its cause is not known. 
Microscopical examinations show that the decalcification occurs first 
in the periphery of the haversian canals and in the inner layers of 
the walls of the marrow spaces. As the salts of lime are removed, 
the basement substance at first remains as a finely fibrillated mate- 
rial still preserving the original lamellation. The bone-cells may be 
changed in shape or degenerated. After a time the decalcified tis- 
sue may disintegrate and be absorbed, and its place occupied by 
newly-formed marrow or granulation tissue. As the disease goes 
on, the marrow tissue is congested and red, the fat absorbed, and 
there is a great accumulation of small spheroidal cells ; or the mar- 
row may assume a gelatinous appearance. The decalcification and 
absorption of the bone from within may proceed so far that the bony 
substance in the cancellous tissue almost entirely disappears and the 
compact bone is reduced to a thin soft decalcified tissue. The dis- 
ease is not always continuously progressive, but may be subject to 
temporary cessation. As a result of this softened condition of the 
bones, the weight of the body and the action of the muscles may 
induce a series of deformities which are sometimes excessive — curva- 
tures of the spine, complete and incomplete fractures of the bones, 
distortion of the pelvis, sternum, etc. There is a tendency in this 
disease to a general involvement of the bones, but the changes are 
sometimes confined to single bones or groups of bones. The cra- 
nium is rarely much affected." ( u Therapeutic Gazette.") 

Treatment. — Archer (on Gynecology) sums up recent experience 
as to this disease. He points out facts to show that the disease is 
not confined to the very poor ; nor is it due to prolonged lactation, 
bad nutrition, damp dwellings, or sour bread. No changes in the 



224 THE PRACTICE OF MEDICINE. 

blood have been demonstrated which can explain its origin. It is 
endemic in certain places, as in the Swiss canton of Basle. It appears 
to be connected with ovarian activity, and the subjects of it are extra- 
ordinarily fertile. He asserts that no treatment cures it with such 
certainty as removal of the ovaries. Sterilization, without removal 
of the ovaries, has not the same curative influence. After removal 
of the ovaries the pain in and tenderness of the limbs, which are 
marked features of the disease, begin to diminish in a few days. 
The disease is a tropho-neurosis of the bones, depending chiefly on 
the ovarian activity. If it occurs in males, as some authors assert, 
it must be due to abnormal activity of the testes. In such cases 
their removal would be required. 

Hofmeier (" Centralblatt fur Gynakologie," No. 12, 1891) reports 
the case of a virgin, aged thirty years, who had osteomalacia of three 
years' standing, the disease being progressive at the time of the 
operation, as shown by the presence of severe pains in the pelvic 
bones, inability to walk, and marked pelvic deformity ; menstrua- 
tion regular and painless. Four weeks after the removal of the 
ovaries the patient could walk without assistance, and the pains were 
much less severe. She received cod-liver oil and peptonate of iron ; 
six weeks later she felt quite well, had no pain, and could walk a 
long distance. The pelvic organs were normal. 

The ovaries were atrophied, as in a woman after the meno-pause, 
and presented a similar appearance microscopically, only a few ovi- 
sacs being seen. The case was interesting, not only because the 
patient was a virgin (hence pregnancy could not be regarded as an 
etiological factor), but there was no disturbance of menstruation, or 
evidence of pelvic congestion. As regards the effects of castration 
under such circumstances, the writer admits, with Fehling, that it is 
impossible to give a satisfactory explanation. It may be due to some 
reflex action upon the vaso-motor nerves supplying the nutrient 
vessels of the pelvic bones, the disease itself being regarded as a 
tropho-neurosis of the bones directly dependent upon ovarian activ- 
ity. This theory receives additional support from a similar case 
reported by Truzzi. Fehling has collected twenty other cases of 
castration for osteomalacia, in none of which was there a failure on 
the part of the operator to secure at least a temporary benefit. 
(" American Journal of the Medical Sciences," July, 1891.) 



CONSTITUTIONAL DISEASES. 225 

" Zwiefel has already proved that after a Porro's operation in a 
case of mollities, the bone disease, usually so intractable, may pass 
away. This result is not invariable after Porro's operation, and when 
it occurs it is apparently due to the removal of the ovaries. Dr. H. 
Fehling has recently noted the above facts in the l Centralblatt fur 
Gynakologie.' He quotes the favorable experience of Hoffa, P. Mul- 
ler, and Winckel, and declares that in eight cases, where he himself 
has removed the appendages in cases of mollities, the results have 
been excellent. In six of these cases the patients had not borne a 
child for at least two years before the operation, yet the disease was 
making active progress, and preventing the patient from working for 
her bread or enjoying life. In most of the cases the arrest of the 
mollities was very rapid ; in the remainder the improvement set in 
slowly, but continued steadily after the operation. These results, in 
Dr. Fehling's opinion, appear to justify the theory that it is the sup- 
pression of the functions of the ovaries that brings about the cure 
of mollities after the extirpation of those organs. Why such a phe- 
nomenon should occur Dr. Fehling does not explain ; but if his the- 
ory be correct we have a new physiological truth of great importance. 
The bones, in respect to their red marrow, are known to be blood 
organs ; now it appears that the ovaries are, at least under certain 
conditions, bone-controlling organs." (" British Medical Journal," 
July 28, 1890.) 

There must be, according to some bacteriologists, a microbe 
peculiar to every disease. The following seems to imply that the 
microbe of mollities has been discovered : 

Starting with the hypothesis that osteomalacia is an infectious 
disease due to the presence of the microbe of nitrogenous fermenta- 
tion, and resting, on the other hand, on the researches of Schlos- 
ing, Muntz, and Warrington, according to whom chloroform rapidly 
destroys the vitality of the nitrogenous ferment, Dr. M. Petrone, of 
Xaples, conceived the idea of treating a case of osteomalacia with 
chloral hydrate, which, as is known, gives off chloroform when in 
the presence of the alkaline fluids of the body. 

" The patient was a woman of fifty. The trunk was a shapeless 
mass : the vertebral column was deflected, twisted, and arched for- 
ward. The woman's height was reduced to 1.3 metres (four feet 
three inches), while before the disease it measured 1.57 metres (five 

15 



226 THE PRACTICE OF MEDICINE. 

feet two inches). The abdomen was very prominent, and there was 
a large hernia of the linear alba. The pelvis offered the character- 
istic deformities of osteomalacia. The bones of the face and cranium 
presented nothing abnormal. The patient experienced continuous 
violent spontaneous pains in the bones, increasing with pressure. 
Walking and even the upright posture was impossible ; the slight- 
est movement to change the position in bed provoked terrible pains. 
Besides all this the patient was tormented by a very annoying cough 
occurring in paroxysms, as well as by an incessant hiccough. The 
urine contained neither albumin nor sugar, but traces of propeptone 
and a notable quantity of nitrous acid. 

" Dr. Petrone instituted the treatment with chloral hydrate, in 
doses of two grammes (thirty grains) a day, in solution. In three 
days, it is reported, the pains had considerably diminished, and in 
the urine the propeptones had completely disappeared and there was 
a notable diminution of the nitrous acid. On the fifth day of the 
treatment the urine had become normal. Toward the end of the 
first week the patient could get up, dress herself all alone, and make 
a few steps without any support. The spontaneous pains had almost 
completely disappeared, the hiccough had vanished, and the annoy- 
ing cough was improved. At the end of a fortnight the patient 
could be considered as cured ; still the treatment was continued for 
a week longer, making in all three weeks of medication. At the 
date of this report there was no longer, it is stated, the slightest 
osseous pain, either spontaneous or provokable by pressure; the 
patient could walk, go up and down stairs, attend to her domestic 
duties, and freely and without pain execute all the movements 
which her osseous deformities permitted of making. The cure 
appeared to be complete, and ascribable to the chloral, that is to 
say, to the chloroform set free by this medicament in the organism. 
The author even considers the several recorded cures of osteomalacia 
after ovarian castration due to the chloroform used for the produc- 
tion of the anaesthesia in the operation." 

In the above case the chloral may have cured by inhibiting the 
functional activity of the ovaries. If Fehling's theory be true, and 
it seems probable, there are medicines which should be used as pal- 
liatives, whose effects are to diminish ovarian and testicular activity 
— conium, iodine, bromine, baryta, morphine, salix niger in large 



CONSTITUTIONAL DISEASES- 227 

doses ; but the objection to their continued use is, that the general 
vitality of the system would be so much depressed that their effects 
could not safely be pushed to the point of causing atrophy of the 
ovaries, and even this might not cure. 

No clinical reports of cures of this disease are to be found in our 
literature. Raue recommends calc. carb., calc. phos., fluoric acid, 
and silica under the old theory that the disease is caused by a defi- 
ciency of the lime salts in the blood. Such remedies are not indi- 
cated. Only those are indicated that act through the sympathetic 
nervous system. 

If we select remedies homeopathic to abnormal ovarian activity, 
they are aurum, murex, platina, asafoetida, sabal serrulata, phos- 
phorus, turnera, and other aphrodisiacs in minute doses (3x to 12x). 



EICKETS. 

[I have quoted freely from the great work of Dr. Eustace Smithy 
on "Diseases of Children,"* because of the excellent manner in which 
the symptoms are there presented.] 

Definition. — U A constitutional diathesis, which impairs the nutri- 
tion of the whole body. Under its influence, growth and develop- 
ment are arrested, dentition is retarded, the bones soften and become 
deformed, the muscles and ligaments waste, and in fatal cases altera- 
tions are often noticed in the brain, liver, spleen, and lymphatic glands. 
The disease usually begins in infancy. It is rare under the age of 
six months, for it seems very doubtful if the cases of so-called con- 
genital rickets are true examples of the disease. At the eighth 
month, however, it begins to be common, and from that age until 
the eighteenth month may be readily set up under the influence of 
causes which interfere with digestion and impede the assimilation of 
food. It is less common for the disease to develop in children who 
have been in good health up to the age of eighteen months, but it 
may occur at any time between that age and the seventh year, or 
even in still older subjects. Although beginning at a very early asre, 
the disease often continues for several years, and may be seen exist- 
ing in a marked degree in children three or four years old. 

* William Wood & Co., New York. 



228 THE PRACTICE OF MEDICINE. 

Causes, — " Kickets is the direct consequence of mal-nutrition in 
early life. Its causes must therefore be looked for in all the diverse 
agencies which impair the nutrition of the growing frame. The 
most important of these are, no doubt, faults of feeding and hygiene. 
Insufficient or unsuitable food stints the body of necessary nourish- 
ment, and an inadequate supply of fresh air renders assimilation 
defective and weakens digestive power. These two causes are most 
commonly found united in the poorer quarters of large cities. An 
infant who lives amongst other children in one small room, where it 
breathes a tainted air, and derives its only nourishment from the 
watery breast-milk of a weakly mother, with the addition, perhaps, 
of a little gruel or sopped bread to quiet it when it cries, can only 
escape rickets by becoming tubercular. By such means an extreme 
degree of the malady will probably be produced. But similar agen- 
cies, although operating in milder form, will produce rickets in any 
condition of life. It is not uncommon to meet with examples of the 
disease in well-to-do families where the child has been kept in-doors 
for fear of his catching cold, and has been supplied with farinaceous 
compounds largely beyond his power of digestion. Over-feeding 
with starch food is a fruitful cause of rickets. The giving of far- 
inaceous matters in excess, or at a time when the glandular secretions 
are insufficient for its digestion, is the commonest fault committed in 
the hand-feeding of infants. Dr. Buchanan Baxter, who tabulated 
120 consecutive cases of rickets, found that in many of them the dis- 
ease dated from the time when farinaceous food was first given. It 
is probable that in these cases the occurrence of mal-nutrition and 
subsequent rickets is due not so much to the excess of starch as to the 
absence of the more nutritious food for which the starch has been 
substituted. Rickety children so fed are often fat, and do not, to the 
inexperienced eye, convey the impression of being under-nourished. 
Examination, however, discovers that they are weak, often exces- 
sively feeble ; and it is evident that the plumpness of the child is due 
to disproportionate development of the subcutaneous fat. This tis- 
sue has been enormously over-nourished, while the rest of the body 
has been stinted and starved. 

" The time of weaning is often a starting-point for rickets, for the 
breast-milk is usually replaced by some preparation of starch. So, 
also, long-continued suckling may induce the disease, for the breast- 



CONSTITUTIONAL DISEASES. 229 

milk after a time ceases to satisfy the infant's wants, and too little 
additional nourishment is supplied. Therefore, whether the food 
given be insufficient in amount or indigestible in form, the effect is 
the same : the child is starved, and rickets become developed. 

" In cases where the child lives in a good bracing air, the effects 
of an unsuitable dietary are less painfully evident. In dry country 
places, where the infant spends much of his time out-of-doors, rickets 
is a more uncommon disease than it is in localities where the con- 
ditions are less favorable to health ; want of sunlight, want of clean- 
liness, and a combination of cold and damp, are other determining 
causes which are not without their influence in the production of 
rickets. All these causes must, no doubt, act with especial energy in 
the case of infants who are naturally weakly, or whose strength has 
been already reduced by some exhausting disease. There are, there- 
fore, many conditions which predispose to the complaint. Feeble- 
ness of constitution on the part of the parents will, no doubt, have 
an influence in this respect, for weakly parents are not likely to beget 
constitutionally healthy children. Moreover, a weakly mother ^is 
usually unable to nurse her baby; and hand-feeding, unless con- 
ducted with extreme care and discretion, is often unsatisfactory. A 
very large proportion of rickety infants are bottle-fed." 

Symptoms. — " As might be expected in a disease which arises as 
a direct consequence of faulty nutrition, the symptoms proper to 
rickets are usually preceded by others indicating a general interfer- 
ence with the nutritive processes. Digestive derangements are com- 
mon, but these comparatively seldom consist in attacks of severe or 
repeated vomiting or diarrhoea. In most cases the derangement is 
limited to a lessening of digestive power, so that the motions, with- 
out being actually loose, are more frequent than natural. They are 
large, pasty-looking, and offensive from the quantity of farinaceous 
and curdy matters which are passing undigested out of the body. 
At this time the child is often irritable and fretful. His belly may 
be swollen from flatulent distention, and he frequently cries with 
pains in the abdomen. For this reason he may be often found asleep 
in his cot resting on his chest, or supported on his knees and elbows, 
with his head buried in the pillow. The urine is often acid, and 
causes uneasiness in micturition. If the child perspires copiously, the 
renal secretion may contain considerable quantities of uric acid sand." 



230 THE PRACTICE OF MEDICINE. 

" Unless, by judicious treatment and diet, the alimentary canal be 
restored to a healthy state, the child, although often still plump to the 
eye, becomes pale and flabby. Then, after an interval which varies 
in duration according to the natural strength of the patient and the 
more or less wholesomeness of his surroundings, the early symptoms 
are noticed. The onset of the disease is announced by three special 
symptoms. The child begins to sweat about the head and neck ; he 
throws off his coverings at night, and lies naked in his cot ; and 
begins shortly afterwards to exhibit uneasiness if much danced about 
in his nurse's arms, or handled without the utmost gentleness. 

" The sweating is profuse and occurs principally during sleep. 
At night, beads of moisture may be seen standing on his brows, and 
the sweat trickles off his head onto the pillow, which is often satu- 
rated by the secretion. If the child falls asleep in daytime, or even 
if he exerts himself much while awake, the same phenomenon may 
be noticed. The irritation of this perspiration often gives rise to a 
crop of miliaria about the neck, behind the ears, and on the forehead. 
The superficial veins of the temples are full, the jugular veins are 
unusually visible, and the carotid arteries may be felt to pulsate 
strongly. 

" The desire of the child to lie cool at night comes on almost at 
the same time with the preceding, and may be observed in the coldest 
weather. It is, indeed, a frequent cause of catarrh in these patients, 
and I have seen many cases in which continued looseness of the 
bowels was apparently maintained by repeated chills so contracted. 
For the same reason a frequent cough from pulmonary catarrh is a 
common symptom. 

" General tenderness usually begins to be noticed at a certain 
interval after the two other symptoms which have been mentioned. 
It is shown by unusual sensitiveness to even slight pressure, and 
appears to be seated in the muscles as well as in the bones. The child 
cries if lifted up at all abruptly or subjected to a jolt or jar, and pre- 
fers to lie quietly in his cot or in the lap of his nurse. This symp- 
tom seldom occurs until the osseous changes are well marked. It is 
accompanied by uneasiness or pain about the head, which is indi- 
cated by a monotonous movement of the head from side to side upon 
the pillow. The hair covering the occiput is often worn away by 
this constant movement, and the bareness of the back of the scalp 



CONSTITUTIONAL DISEASES. 231 

from this cause is a very characteristic symptom. Tenderness is not 
always noticed. It is usually confined to cases where the disease is 
severe. In the mild cases, which are shown merely by a slight 
enlargement of the wrists and ankles, without any apparent soften- 
ing of the bones, the symptom is usually absent. 

" In a pronounced case of rickets, the effect of the bone lesion is 
very striking and peculiar. The skull is large, with a long anterio- 
posterior diameter, and often, on account of the comparatively small 
size of the face, looks larger than it really is. The forehead is 
square from exaggeration of the bosses of the frontal bones, and is 
sometimes very prominent from the development in the bone of cel- 
lular cavities. The fontanelle is large and remains open long after 
the end of the second year. Sometimes, if the size of the brain is 
increased, or there is excess of fluid in the skull cavity, the sutures 
in connection with the fontanelle can be felt to be more or less dis- 
tinctly gaping. On account of the thickening of the edges of the 
flat bones the margins of the sutures and fontanelle are elevated, 
so that the latter feel depressed and the sutures are indicated by 
furrows. The posterior fontanelle has usually disappeared before 
the beginning of the illness, but in extreme cases, where the disease 
began early and the symptoms are pronounced, it may be felt to be 
still unclosed. 

"The chest is deformed in a very characteristic manner, on 
account of the inability of the softened ribs to resist the pressure of 
the atmosphere. Under normal conditions, when the ribs rise and the 
chest expands in the act of inspiration, the solid framework of the 
thorax is able to withstand the pressure of the expired air, and the 
chest easily enlarges to allow of inflation of the lungs. Air rushes 
through the windpipe to dilate the pulmonary tissue in proportion as 
the chest-walls expand. In the rickety chest, on the contrary, the ribs 
are not firm but yielding. Consequently the framework of the thorax 
is not rigid enough to resist -the pressure of the air from without, 
and when the effort is made to expand the chest the softened ribs 
are forced in at the sides, the parts where they are least supported. 
This sinking-in of the ribs throws the sternum forwards. We there- 
fore find the chest grooved laterally and the breast-bone prominent 
and sharp. 

" The spine is often bent. In an infant the cervical curve is 



232 THE PRACTICE OF MEDICINE. 

increased so that the head is supported with difficulty and falls back- 
ward upon the shoulders, producing a very characteristic attitude. 
Also, the weight of the head and shoulders, as the child sits bending 
forward, causes a projection backward of the dorsal and lumbar 
spines, which is sometimes so sharp as to give the appearance of ver- 
tebral caries. The deformity, however, subsides completely when 
the child is taken up under the arms and the spine is drawn upon 
by the weight of the limbs and pelvis. If the patient is able to 
walk, there is an increase in the lumbar and dorsal curves. The 
curvatures may be lateral. If the child is carried habitually on his 
nurse's left arm, the trunk sways over to the right ; if on the right 
arm, the body leans to the left. In all these cases the deformity is 
due to weakness of the ligaments and muscles. The bones forming 
the pelvis may be also deformed, and sometimes, like the chest, are 
greatly distorted." 

Complications. — " It is not often that a case of rickets remains 
uncomplicated by some intercurrent complaint. The subject of a 
pronounced form of rickets has but little resisting power, and is 
readily affected by any kind of injurious influence. But he is, in 
addition, peculiarly liable to certain forms of derangement on account 
of the special tendencies of the phase of mal-nutrition. The sensi- 
tiveness to chills manifested by a rickety child has been already 
remarked upon. This proneness to catarrh may be the consequence 
of the profuse and ready action of the sweat-glands, and it is no 
doubt encouraged by the child's practice, when his perspirations 
begin, of throwing off the coverings of his bed. The various forms 
of catarrh are therefore especially liable to occur, and pulmonary 
and intestinal catarrhs are the most frequent of these derangements. 
Few rickety children are without a cough, and this symptom, on 
account of the unnatural flexibility of their chest- walls, must be 
always regarded with anxiety. More or less intestinal catarrh is a 
common derangement in this disease, and after any unusual expos- 
ure the looseness of the bowels may pass into a severe attack of purg- 
ing. Diarrhoea, on account of the great general weakness, is a source 
of extreme danger, and during the changeable seasons of the year 
many children are carried off by this complaint. 

" Another peculiarity of the rickety state is the curious impress- 
ibility of the nervous system, which manifests itself by the ready 



CONSTITUTIONAL DISEASES. 233 

occurrence of various forms of spasm. Reflex convulsions are com- 
mon, and laryngismus stridulus is practically confined to the subjects 
of rickets. Catarrh of the larnyx is also liable to be accompanied 
by spasm, and therefore catarrhal croup (laryngitis stridulosa), as 
is elsewhere stated, is a frequent cause of anxiety." 

Diagnosis. — " In a mild case of rickets, the prominent features 
are the swelling of the epiphysisal ends of the long bones, the tardy 
eruption of the teeth, and the backwardness in learning to walk. If 
we notice the wrists to be large in a young child, we should at once 
count the number of his teeth and ask if he can stand alone. If a 
child ten months old shows no sign of a tooth, if his wrists are large, 
and if, when held upon his feet, his limbs double up helplessly 
beneath him, there can be little doubt that he is the subject of rick- 
ets. Even before the swelling of the articular ends of the bones has 
come on, the onset of the disease may be suspected. Big, fat, flabby 
infants are generally slightly rickety, and if a child sweats profusely 
about the head, and is kept covered at night only with great diffi- 
culty, we can have but little doubt that the characteristic signs of 
rickets are about to appear. In such a case, attention should be at 
once directed to the child's diet, the regularity with which he is 
taken out-of-doors, and the state as to ventilation of his sleeping- 
room, so that any errors in management may be promptly corrected. 
In a marked case of rickets, the deformity of the chest, the bending 
of the bones, the enlargement of the joints, and bending of the ribs 
are sufficiently characteristic. Even the position of the patient, as he 
sits with his legs crossed and his head fallen back between the shoul- 
ders, supporting his feeble spine by his hands placed before him on the 
floor, enables us at once to recognize the case as one of well-defined 
rickets. The complete uselessness of the lower limbs in many of these 
cases is often a serious anxiety, even to parents who regard the other 
symptoms with comparative indifference, for they fear lest the child 
should be 'going to be paralyzed.' But although the patient has no 
idea of even placing his feet upon the ground, and cries bitterly when 
any attempt is made to persuade him to do so, power of movement 
of the legs is unimpaired. If the skin of the legs be pinched or 
gently pricked, he at once draws his limbs out of the way." 

Prognosis, — " Rickets is not a fatal disease in itself unless the 
bony change be far advanced, nor even in such a case does death 



234 THE PRACTICE OF MEDICINE. 

often ensue except as a consequence of some catarrhal complication. 
As a rule, improvement begins directly measures are taken to amend 
the unwholesome conditions in which the patient is living. The dan- 
gers of pulmonary catarrh and atelectasis in a child with great 
deformity of chest are elsewhere referred to ; and the serious conse- 
quences which may result from diarrhoea in an infant reduced to a 
state of serious weakness by chronic mal-nutrition need not be insisted 
upon. Of the nervous complications, laryngismus stridulus is some- 
times a cause of sudden death, but reflex convulsions, excited by 
some trifling irritant, rarely have any ill results." 

Treatment. — " In every case of rickets, our first care should be 
not to give cod-liver oil or tonics, but to inquire into the conditions 
in which the child is living ; to ask about the food he is taking, the 
quantity allowed for each meal, the frequency with which the meals 
are repeated, and the degree of cleanliness of the feeding apparatus. 
We should then turn to the subject of his clothing, the ventilation of 
his bedroom, and the number of hours he is passing out of doors. 
The real treatment consists in attention to all these important mat- 
ters, and not solely in the administration of any particular drug. 
Medicines are no doubt useful with that of a reformation of the 
unwholesome conditions under which the failure in nutrition has 
taken place. 

" Plenty of fresh air should be insisted upon. The child, warmly 
clad, should be sent out in all suitable weather, and if care be taken 
that his feet are well warmed before he leaves the house there will 
be little danger of his catching cold. If the patient has reached the 
age of eight or ten months, he should be carefully packed with cush- 
ions in a perambulator and in cold weather should always have a hot 
bottle at his feet while out of doors. The ventilation of his sleeping- 
room must be attended to. A small fire in the winter, and a lamp 
placed in the fender during the summer months, will insure a suffi- 
cient circulation of air through the bed-chamber. Both the patient 
and his immediate surroundings must be kept scrupulously clean. 
Every morning the whole body should receive a thorough washing 
with soap and water, and be well sponged in the evening before the 
child is put in his cot. On account of the copious perspiration, his 
body linen, as well as that belonging to his cot, soon becomes satu- 
rated with moisture. His underclothing should therefore be changed 



CONSTITUTIONAL DISEASES. 235 

as often as is necessary. Every morning, too, his mattress and bed- 
coverings must be thoroughly exposed to the air. The sheets also 
should be changed frequently and be carefully aired." 

The homeopathic treatment of rickets by means of medicines does 
not show any brilliant success, unless it is attended by the hygienic 
and dietetic measures advised by Dr. Eustace Smith. I do not 
advise washing the child with soap and water unless the skin is well 
rubbed with some penetrating fat, like pure lard, fresh butter, or cod- 
liver oil. It should be made to eat fat in some form. Few children 
will refuse butter or bacon if mixed with their starchy food. 

Dr. J. Oscoe Chase in the " Homeopathic Journal of Obstetrics " 
for July, 1892, says : "In the matter of treatment, we must have, in 
the first place, due regard for the hygienic surroundings and dietetic 
treatment. The child suffering from rickets in the acute stage 
requires albuminous and fatty foods in the most concentrated and 
easily digested forms, while saccharine and starchy foods must be 
avoided, or be taken in the most moderate quantities. In regard to 
the therapeutic action of drugs, the specific salts, especially in- bone 
disease, must be given low. It has been proven that prolonged 
doses of phosphorus, and to some extent lactic acid, will produce 
rickets or osteomalacia ; thus we have a scientific basis to work 
upon, and the large number cured from phosphorus shows that the 
law of similia is the most applicable. Jacobi says that 'minute 
doses of phosphorus renders the newly-formed tissue at the point of 
opposition of the bones more compact in a very brief time.' Wag- 
ner, twenty years ago, demonstrated this by his experiments on ani- 
mals, which has since been confirmed by Kasowitz, of Vienna. The 
latter reported 560 cases of rickets, in which he gave phosphorus, 
1-126 of a grain two or three times a day, resulting in the skull 
becoming harder, the fontanelle smaller, the softening of the bones of 
the thorax and extremities to disappear, and all the other symptoms of 
rachitis to improve. Others of our allopathic brethren say that even 
smaller doses of phosphorus are just as beneficial. Mandelstamm 
used phosphorus in 216 cases of rickets. In 120 a complete cure 
was affected, and 43 were improved. The duration of treatment was 
from one month to one year, and the remedy was administered in a 
simple emulsion or with cod-liver oil. From the various sources that 
I have been able to consult, and with what experience I have gained, 



236 THE PRACTICE OF MEDICINE. 

the best remedies for rachitis are the salts of lime, soda, and potash,, 
with their compounds. Calcarea phos. stands preeminently at the 
head, and with calcarea flor., calcarea sulph., and phosphorus, we have 
our sheet anchor in diseases of the bones and connective tissues. Fer- 
rum phos., for affections of the blood and muscles ; kali mur., for 
the mucous membrane ; kali phos., for atrophic conditions ; kali 
sulph., for skin affections ; magnesia phos., for functional and ner- 
vous disorders ; natrum mur., in cartilaginous changes ; natrum 
phos., for increased acidity of the digestive organs ; natrum sulph., 
for increase in serum ; and silicea in glandular and suppurative dis- 
turbances." 

Other writers of our school recommend the following : 

Calcarea phos. — In delicate children caused by soft sponginess 
of the bone from want of phosphate of lime molecules. " Skull soft 
and thin, with crackling noise when pressed upon, delayed closures 
of fontanelles, sallow, earthy complexion, face pimpled, retarded den- 
tition, emaciation, lateral curvature, swollen condyles in both extrem- 
ities, spina bifida, non-union of broken bones, systemic dyscrasias, 
Pott's disease, shrunken children, hard lumps on the cranium, diar- 
rhoea during dentition with much flatus, cold tremors, child cannot 
hold head upright." Its principal indications are the fontanelles, 
which remain wide open, the diarrhoea, and emaciation of the child. 

Kali phos. — Atrophy of the bones, with putrid smelling dis- 
charges from the bowels. 

Natrum mur. — Particularly useful when the thighs are notably 
emaciated and the disease in its early stages, with slight pliability of 
the bones. 

Silicea. — Open fontanelles, head too large and rest of the body 
emaciated, with pale face ; abdomen swollen, hot ; ankles weak ; 
profuse head-sweat and body dry; likes wrapping up warmly; 
offensive diarrhoea, stools contain undigested food, with great exhaus- 
tion, but painless ; inflammation, swelling and suppuration of glands 
and bones ; ulceration and necrosis ; cellular inflammations ; boils, 
abscesses, etc., with tardy recovery and subsequent induration. 

Dr. Knuppel, of Madgeburg, reports (Allg. Horn. Zeit., p. 4) 
cases where formerly children had been born rachitic, exhibition of 
calcarea phos. during last months of pregnancy had entirely pre- 
vented it, and children were born healthy. 



CONSTITUTIONAL DISEASES. 237 

I have found the muriate of lime, in appreciable doses, the most 
efficient. I usually prescribe it in a syrup made of glycerine and 
water (one-half of each), each drachm containing one grain, and 
three teaspoonfuls to be given each day. 



FURUNCLE. 

Definition. — A boil is an intense inflammation, occupying, within 
a well-defined area, the entire thickness of the skin (inclusive of the 
sub-cutaneous tissue) , and attended almost always with circumscribed 
suppuration and formation of slough. Boils may appear singly or 
in crops, or follow each other in succession. The first indication is a 
small induration of the skin, which is tender to the touch. It increases 
in size for several days, when it presents a circumscribed suppura- 
tive centre called a " core." The pain is throbbing, deep-seated, and 
worse at night. It is distinguished from carbuncle by its small size, 
pointed shape, and single centre. Boils are not always caused by a 
u low depraved state of the system," as some assert. They are not 
absent in robust health. Young persons are especially liable to them, 
while the carbuncle is more apt to occur after middle life. 

Treatment. — Arnica and bellis perennis are indicated in all sim- 
ple furunculi. They should be applied locally in mild cases, a five 
per cent solution, and given in doses of a drop of the tincture every 
three hours. It is said that phytolacca, lycopodium, and hepar sul- 
phur will prevent their frequent recurrence. If a stinging pain 
marks their access, apis may abort it. When suppuration is impend- 
ing, hepar sulphur 2x may arrest it or prevent extensive sloughing. 

Arctium lappa (burdock) is an old remedy for chronic recur- 
rence of boils. I have verified its value in many cases by giving it 
in doses of ten to fifteen drops of the tincture, three times a day for 
weeks or months. Berberis aqui. has the same reputation. The 
water of sulphur springs has been of great value in this diathesis. 
Many cases which had resisted all medicines, diet, and hygiene, have 
been cured by a regular use of such waters as the Avon in New York, 
the Delaware in Ohio, or the French Lick and Baden in Indiana. 
The two last mentioned springs have attained a wide and deserved 
popularity. A few weeks' residence at the springs, drinking the 
water (not in excess), has cured the most inveterate cases. 



238 THE PRACTICE OF MEDICINE. 

Many methods have been recommended for the abortion of boils. 
An ointment of nitrate of mercury is highly praised. Pure benzine, 
applied on cotton frequently, only a minute at a time, is said to be 
effectual. As in erysipelas, the aim of the abortive, or any treat- 
ment, is to destroy the pyogenic coccus. It has always seemed to me 
that external applications were about as illogical as throwing water 
on the roof of a house to put out a fire in the basement. We should 
aim to reach the nucleus or focus. I used at first a Hve per cent 
solution of carbolic acid, but it was not strong enough. Afterwards 
I increased the strength until I used a fifty per cent solution. This, 
if injected into the centre of the nodule, before necrosis has taken 
place, will with absolute certainty prevent further progress. Not 
more than two or three drops is necessary. It causes very little 
pain, and that only when the needle penetrates the skin. When a 
pustule has appeared at the apex, showing beginning of suppuration 
in the centre, more should be used, — ten to fifteen minims. After 
the injection, press on the swelling, in order to diffuse the carbolic 
acid. I have often used the ninety-five per cent solution, with no 
bad results. When the core has formed or has been expelled, a fifty 
per cent solution injected into the cavity prevents the migration of 
the cocci into the surrounding tissues. If, however, small red nod- 
ules have formed adjacent to the original boil, each one should be 
injected with carbolic acid. I would suggest a trial of methyl vio- 
let (pyoktanin) in the suppurative stage. It may prove more effect- 
ual than carbolic acid. I never poultice boils. It will certainly 
favor the spread of the cocci. An external application of a strong 
solution of boric acid, borated calendula, thymol, or eucalyptol water, 
on absorbent cotton, is far better than a poultice, and if used hot, 
relieves the pain and tension just as effectually. 



CHAPTER V. 
DISEASES OF THE RESPIRATORY SYSTEM, 



ACUTE CORYZA. 

Definition. — An acute catarrhal inflammation of the mucous mem- 
brane lining the nose and the cavities communicating with it. In 
the first stage the capillary vessels become engorged with blood ; 
this occasions swelling of the mucous membrane which becomes infil- 
trated and edematous, and a quantity of colorless, salty, very thin 
liquid flows from the nostrils. In the second stage the secreted 
liquid becomes thicker and opaque, and the hyperemia and swell- 
ing of the membrane diminishes. Sometimes the exudation is fibrin- 
ous, similar to that of diphtheria, especially in children. These secre- 
tions are at first odorless, but later become nauseous and sometimes 
foetid, and the taste bitter or musty. In the third stage the mucus 
may form hard crusts in the nostrils, or on the septum and turbin- 
ated bones, and in children it may completely close the nostrils. It 
may be bloody and the nose may bleed profusely. This bleeding 
usually gives considerable relief. The secretions may be so acrid as 
to irritate the nose and upper lip until they become red, swollen, and 
eroded. The inflammation by extending to the ethnoid and sphenoid 
cavities, may cause pain in the forehead, root of the nose, the frontal 
sinus, or in the malar region if the antrum is inflamed. It may 
extend up the eustachian tube, causing deafness, noises in the ears, and 
otalgia, y It often extends down the posterior nares to the pharynx, 
larynx, and bronchi. The sense of smell is blunted and often tem- 
porarily absent, as is also the sense of taste. The fever is usually 
slight but may run high, even to 105°, and is remittent. This is 
the catarrhal fever, mentioned in some text-books, and is attended 
by soreness of the muscles, rigidity of the joints, and fits of chilli- 
ness on the slightest exposure to cold air. The fever may last only 



240 THE PRACTICE OF MEDICINE. 

a few days or may continue until the seventh day. It is generally 
supposed that a coryza is caught by exposure to cold and damp air, 
but I think it is often contracted by going from a cold atmosphere 
to a hot room, especially if the hot air is impure. There are times 
when the air is so damp and cold, especially at night, that almost 
every person exposed to it is attacked with coryza. There is a class 
of " cranks " who have an idea that they should open the window in 
their sleeping rooms every night, even when the air is cold, damp, 
and foggy. They get into bed and consider themselves safe from a 
catarrhal attack. They do not realize that breathing this air has the 
same effect as if they exposed the nude body to it. There are other 
" cranks " who pretend to believe that under all circumstances night 
air is as pure and safe as day air. They forget that the absence of 
the sun's rays is what makes night air less healthful than day air. 
It is always damper, and poisonous spores and germs are in much 
greater numbers in it. Rooms should be ventilated in bad weather 
without opening the windows. If there is an opportunity for bad 
air to get out of a room it will be replaced by better air from some 
other source. If a transom is open, and a strip of wood three inches 
wide placed under the lower sash of a window, fresh air will pass 
into the room and circulate without causing draughts. There are 
many persons who feel the first symptom of a coryza in the pharynx. 
It generally appears at night and awakens the patient with a hot, 
dry sensation at a small spot back of the soft palate. This irrita- 
tion, passing upward into the nose, causes sneezing, and downward 
into the larynx and bronchi, cough. 

Treatment. — If the patient will consult a physician of our school 
on the appearance of the initial symptoms, the " cold " or coryza 
can be aborted. If he will go to bed, drink slowly a tumbler of 
hot water in which are a few drops of tincture of camphor, he 
will soon perspire and in a few hours feel as well as usual. Another 
method is to take a drop or two of gelsemium every hour, or a 
tablet of gelsemium and camphor lx every half hour ; the catarrh 
may then be arrested in a few hours. Aconite lx is used by many 
as an abortive in colds, one drop every hour. An unfortunate and 
delusive belief has taken possession of a large number of physicians 
and the laity, that quinine will " break up a cold." There is not a 
particle of evidence that quinine can abort or mitigate an attack of 



DISEASES OF THE RESPIRATORY SYSTEM. 241 

catarrh. On careful inquiry I find that when benefit is claimed for 
it, the drug was taken with some hot drink and the patient brought 
on a perspiration. Instead of being of any value, it is a positive 
injury in the doses usually taken, two, five, or ten grains, for it 
produces congestion of the head, ears, nose, and eyes ; and the 
engorgement of their blood-vessels favors inflammatory sequences. 
I admit that if used in minute doses it may be of value in conges- 
tive catarrhs, but the dose should not exceed the one-hundredth of 
a grain every two hours. The arseniate of quinine, if indicated, is a 
useful remedy, especially when hot, impure air is the cause of the 
coryza. 

Many resort to the Turkish or Russian baths in the beginning 
of a cold ; but in our climate it is a hazardous procedure. Many 
deaths from pneumonia have been caused by this unreasonable 
method. A hot-air bath, taken in one's own room, with the tem- 
perature at 90° or 100°, and followed by an inunction of cocoa but- 
ter or vaseline, the patient going to bed, while the room cools grad- 
ually to 70°, is better than any other kind of bath. A hot-water 
bath under similar circumstances is admissible. The administra- 
tion of one-eighth grain of pilocarpine when the patient is in bed, 
will cause profuse perspiration. If there is a good deal of pain and 
soreness of the joints and muscles, gelsemium will generally relieve ; 
if not, three grains of phenacetine every hour will give ease and 
sleep. The medicines adapted to the symptoms of a coryza after 
the initial stage, for their various manifestation, are many, and each 
case must be studied by itself. Those most often indicated are 
arsenic, arum, allium, euphrasia, bichromate of potassium, iodide 
of potassium, lachesis, phytolacca, nitrate of sanguinaria, sticta, and 
sabadilla. Iodine is probably the nearest to a general similium in 
all cases of catarrh of the air-passages. The iodides of arsenic, gold, 
silver, mercury, and antimony are all useful. 

I need not advise the wearing of wool next the skin all the year 
in this climate, keeping the feet warm and dry, and rapid cold 
sponging if it agrees with the patient ; all these should be adopted 
as prophylactic measures. Bathing should be judiciously practiced. 
Many bathe too much with soap, and render the skin so devoid of its 
natural oil that they are more likely to contract catarrh. Some of 
the greatest sufferers from catarrh, and those most apt to take cold 

16 



242 THE PRACTICE OF MEDICINE. 

on the slightest exposure, have been permanently cured by relin- 
quishing the habit of bathing with soap all over every day, and 
instead of this, annointing the whole body with some pure oil. The 
normal skin of a healthy person is saturated with oil ; and the prac- 
tice, therefore, of oriental nations, of rubbing oil into the skin after 
bathing, is founded on a correct physiological principle. Hydro- 
pathy, as it was practiced many years ago, deprived the skin of its 
natural oil; the consequence was that the skin became like parch- 
ment, or had a satiny feel and appearance, totally unlike the skin of 
a healthy human being. 

Are colds infectious ? This question is discussed by Mr. Hutch- 
inson in the number of his Archives for December, 1891. He 
remarks that "colds" are capable of origination by influences brought 
to bear on the nervous system, and their secretions become infectious. 
He writes : " Thus many catch cold from exposure to draughts or 
damp, and many others from personal infection. No distinction is 
to be drawn between the two; they are as a rule exactly alike. 
Those which arise from infection may, however, be developed into 
special virulence, and may then prevail as epidemics, which are 
attended by more or less individuality of type. Probably infection 
is the cause of by far the greater number of common colds. Infec- 
tion may be believed to be always at work when a cold goes through 
the family." 

As I remarked above, impure air may cause an acute catarrh. 
This is especially true when the close heated air of a room is made 
impure by the exhalations from the noses of persons suffering from 
acute and chronic catarrh. The spores of ordinary catarrh and epi- 
demic influenza cannot be the same. The epidemics of " epizootic " 
and " pink eye " are probably of a catarrhal nature. 



CHEONIC COEYZA. 

Definition. — Chronic catarrh of the nasal passages is divided 
into two forms: the dry and the humid. In the former there is lit- 
tle or no discharge, the patients complain of great dryness of the 
nose, and on examination the membrane looks dry and dull, not glis- 
tening. Thin crusts adhere to the surface. There is no obstruction 



DISEASES OF THE RESPIRATORY SYSTEM. 243 

to nasal breathing, for the fossae are roomy. This variety affects 
the eyes unpleasantly ; the tears do not flow through the nasal ducts ; 
constant, disagreeable lachrymation is the rule, especially if the eyes 
are exposed to a cold wind. The caliber of the duct and of the 
punctum of the eyelid is lessened ; and there is a chronic persistent 
catarrhal conjunctivitis. The expired air from the nose is quite 
offensive, and the sense of smell is lost. There is almost constant 
frontal headache, and pain in the malar bones, and the patient is 
subject to facial neuralgia, affecting principally the fifth pair of cra- 
nial nerves. 

In the humid variety there is an almost constant discharge of mu- 
cus, which may be white, yellow, green, brown, or bloody, and some- 
times purulent. This mucus may become thick and tenacious, and 
form plugs or masses having the appearance of scabs, with an offen- 
sive odor. The passages are generally obstructed, both at the same 
time or singly, worse during damp weather or in impure air. If 
chronic catarrh is neglected or improperly treated, the mucous 
surfaces become ulcerated and lead to that most disagreeable . and 
offensive symptom, ozcena, which almost banishes its victim from 
society. 

Treatment. — In large towns and cities there are specialists 
who make a study of catarrhal and other diseases of the throat and 
upper respiratory passages. Many of them are charlatans who use 
this specialty as a means of making money out of ignorant patients. 
Others are honest and painstaking, who try to render good service. 
In small towns and villages the general practitioner is obliged to 
treat these diseases, and it is his duty to acquaint himself with the 
most modern scientific measures for success. He should study the 
works of Robinson, Bosworth, Rumbold, Morse, Dunn, and other 
authorities on this subject. The constitutional treatment is import- 
ant. It is not often that a person in good general health is afflicted 
with chronic catarrh. There will be found an impoverished condi- 
tion of the blood from malaria or malnutrition ; the patient's cloth- 
ing is not suitable, or his surroundings are not hygienic, or he 
indulges in alcohol to excess. 

A common cause of chronic catarrh is excess or deficiency of 
under-clothing. One extreme is as bad as the other. Too thick 
under-wear is a common fault, the skin is kept too warm and per- 



244 THE PRACTICE OF MEDICINE. 

spiring, and the body rendered very susceptible to changes of tem- 
perature. Indulgence in hot baths, Russian or Turkish, contrary to 
the popular belief, produces a liability to catarrh, especially in our 
variable climates. The cool, quick sponge bath every morning is 
a better protection. 

I shall not attempt to mention all the medicines useful in chronic 
catarrh. Nearly all our principal drugs may be indicated. I have 
found of most value iodide of arsenic, gold, iodide of lime, cubebs, 
copaiva, iodide of barium, eucalyptus, graphites, hepar sulphur, 
hydrastis, iodine, bichromate of potassium, iodide of potassium, iodide 
of mercury, phytolacca, naphthaline, sambucus, penthorum, terebene, 
nitrate of sanguinaria, sticta, sabal, iodide of sulphur, and sepia. All 
the iodides are useful, and cannot be dispensed with. It is difficult to 
give a separate list for the treatment of each variety of coryza, since all 
the real catarrhal remedies, especially the iodides, cause primarily a 
humid, and secondarily a dry or ulcerative catarrhal disease, making 
them useful in all the stages. One fact based on this must be remem- 
bered, namely : that when they are given for acute or humid catarrh 
the dose should be minute, and when given for the dry or ulcerative 
form, more material quantities should be used. 

The diet of catarrhal patients should be liberal, but digestible. 
Naso-pharyngeal catarrh is aggravated by deranged conditions of the 
stomach. Foods containing fats should be used ; sugar and pastry 
avoided. Cod-liver oil, maltine, iodide of iron, and the hypophos- 
phites aid in building up the system and render specific treatment 
more beneficial. 

The internal administration of nearly all the indicated remedies 
should be attended by their topical use. The nasal passages should 
not only be kept clean and aseptic, but should be subjected to the 
local influence of the appropriate medicine. It is utterly impossible 
successfully to treat severe cases by internal medicine alone. 

To illustrate my method of using the appropriate remedy let us 
suppose that bichromate of potassium is indicated by the tough, 
membraneous discharge, the ulceration, the scabby formations, etc. 
Give the 6x on the tongue every six hours, and in the interval, every 
six hours, apply a spray of the same drug, one grain to the ounce. 
If we select one of the insoluble iodides, use the drug internally and 
pure iodine, one or one-half per cent solution, locally. 



DISEASES OF THE RESPIRATORY SYSTEM. 245 

There are some drugs in the following list of great value when 
used topically, that are of no value internally. 

Aristol, boric acid, carbolic acid, fluorsilicate of sodium, resor- 
cin, thymol, ichthiol, eucalyptol, cubebs, copaiva, myrtol, lysol, 
benzo-napthol, naphthaline, oil of sabal, menthol, oil of gaultheria, 
chromic acid, bichloride of mercury, and peroxide of hydrogen. All 
cf these are antiseptics and disinfectants, and exercise an alterative 
influence on mucous surfaces. Most of them are homeopathic to 
catarrhal conditions, because when used in a crude state they will 
cause abnormal discharges, ulceration, and destruction of mucous 
membranes. Of the above list I prefer boric acid, two per cent ; thy- 
mol, 1 to 500 ; resorcin, two per cent ; eucalyptol, one per cent ; oil of 
sabal, five per cent; and chromic acid, 1 to 1000 ; very rarely do I 
use the bichloride of mercury, for it is serviceable only in syphilitic 
cases, it should not be applied stronger than in a 1 to 5000 solution. 
Resorcin and thymol are the two favorite remedies of the best special- 
ists. Resorcin has a great affinity for oxygen, absorbs it from the 
tissues, and reduces congestion and inflammation by contracting 
the vessels ; in hypertrophic catarrh it contracts the tissues, and this 
effect lasts a long time ; it leaves no bad result, no hypersensitive 
condition, as does cocaine (which should be applied only as a tem- 
porary expedient), and can be used continuously for a long time 
without any reaction ; but it should be absolutely pure. In dry 
catarrh I find a four per cent ointment in liquid vaseline very pleas- 
ant to the patient. 

Thymol is better adapted to dry catarrh, as a very weak solution, 
1 to 1000, will restore the secretion and disinfect the passages. If 
the patient dislikes the odor, add a few drops of oil of gaultheria to 
the solution. 

Albolene or benzoinol makes the best vehicle. The purified 
liquid oils, of which liquid vaseline is the type, have become very pop- 
ular vehicles for all the medicines soluble in them. They generally 
agree with the patient, and are soothing to mucous surfaces. There 
are patients who complain of them, believing that they experience 
better effects from watery solutions. The experience of specialists 
is, that we should test both watery and oleaginous solutions. 

The oil of sabal (saw palmetto) is one of my favorite local appli- 
cations ; it closely resembles resorcin in its effects. There is at first 



246 THE PRACTICE OF MEDICINE. 

a pungent, burning sensation, owing to a volatile constituent, but 
after this has passed off, a soothing anaesthetic sensation is obtained. 

Next in order I prefer eucalyptol prepared with albolene or in 
water, after the method heretofore given. The pleasantest of all the 
oils of any value in catarrh, is the oil of white pine needles. It is 
distilled from the needle-like leaves ; the odor is fragrant and deli- 
cious, and I never had a patient object to it ; it is not irritating 
unless the membrane is raw and eroded. A five or ten per cent 
solution in liquid white vaseline is an elegant preparation. It is 
equal in antiseptic and disinfectant properties to most of the above 
named drugs. 

There are hundreds of ingenious hand and steam atomizers in 
use, the principal requisite of which is that it throws a spray, fine 
or coarse as required, and that the spray should be continuous and 
not intermitting. 

Ointments and nasal suppositories or pencils holding the selected 
remedy will prove of value in some cases. Polypoid excrescences, 
or real polypi, if found in the nasal passages, can sometimes be 
removed without the operation of extirpation. Thuya (ten per cent) 
sprayed upon them will often cause their disappearance, especially 
if they are pedunculated. Nitrate of sanguinaria 1 to 1000, and 
chromic acid 1 to 1000, used as a spray, have been found useful in 
nasal polypi. 

Ulcers in the anterior nares or on the septum, and fissures on the 
margin of the alae, should be treated more thoroughly than is usually 
done, in order to prevent the bacillus of erysipelas from entering 
them. The ulcers should be touched with carbolic or chromic acid, 
fifty per cent, or pyoktanin, if they are deep and suppurating. If 
there is yet only an erosion or abrasion, an application of a five per 
cent solution of nitrate of silver will prevent ulceration. 

Bichromate of potassium is the best internal remedy. The fis- 
sures should be treated on the same plan as those of the anus. 
Stretch the margin of the alae until the fissure is deepened, then 
with a pointed glass rod lightly touch the bottom with fuming 
nitric acid ; or the fissure can be made slightly deeper with the 
knife, and then treated with nitric acid, or nitrate of silver. 

Follicular disease of the naso-pharyngeal space is one of the most 
frequent complications of nasal catarrh. The discharge which flows 



DISEASES OF THE RESPIRATORY SYSTEM. 247 

down the posterior nares irritates the follicular glands and excites 
them to increased secretion ; they swell, and finally become hyper- 
trophic, a condition that remains circumscribed to the vault of the 
pharynx in its median portion, although it is no uncommon occur- 
rence to find it developed also upon the lateral walls around the 
eustachian orifice, as well as upon the posterior and superior por- 
tion of the soft palate, giving a mamillary aspect to the turbinated 
bones themselves. In very old cases of naso-pharyngeal follicular 
disease, the mucous membrane becomes much atrophied, the hyper- 
glandular development subsides, and there is diminished secretion 
from the affected region. In this variety we are apt to have a some- 
what glazed or dry appearance of the pharyngeal wall which extends 
itself sooner or later into the median portion of the pharynx, an 
appearance, but not a real ulceration. Inspissated mucus is often 
found blocking up the eustachian orifices, or filling the neighboring 
depressions. We find numerous granulations with depressed mucus- 
covered inter-spaces all over the posterior pharyngeal wall. Besides 
this there are many enlarged and tortuous vessels winding over the 
infiltrated and inflamed surface of the pharynx, and pillars of the 
fauces. The aspect of the former is oftener mottled, although of a 
predominating slate color, owing to the varied hue of the granu- 
lations. 

The symptoms of this disease are (1) a sensation of stuffiness, 
or oppressive fulness in the superior and posterior portion of the 
nasal passages ; (2) the falling down from the palate, and from the 
posterior nares of a greater or less quantity of mucus, which, accord- 
ing to the age, extent and severity of the disease, may also vary in 
physical characters. It may consist of small starchy pellets, or 
masses of viscid, tenacious and almost colorless secretion, without 
odor, which are surrounded by a foamy, aerated expectoration, or of 
larger, heavier, yellow or greenish mussel-like conglomerations of an 
essentially muco-purulent nature ("Robinson on Nasal Catarrh"). 
At first it is easy for the patient to detach these masses by " hawk- 
ing/' but after they become tough and adhere to the walls, it is dif- 
ficult to do so. In children, who do not seem to have the power to 
detach them, these masses are often seen hanging down from the 
nares in great quantity. In a day or two they part with their watery 
portion, become dry, and look like bone. They are sometimes mis- 



248 THE PRACTICE OF MEDICINE. 

taken for diphtheritic membrane, especially when they take on a 
foetid odor owing to decomposition ; and they may poison the blood 
if there are any abraded surfaces there to absorb the poison. They 
are so difficult to detach that it requires long douching through the 
anterior nares with glycerine and water mixed with alkalies. They 
interfere with normal breathing through the nose, and prevent sleep 
by the constant desire to "hawk," or swallow. Children suffer 
greatly from the presence of these masses. It prevents their sleep- 
ing ; makes them nervous and irritable ; destroys their appetite ; or 
causes nausea and vomiting of food, especially in the morning. 
Adults who use liquor to excess are great sufferers from this disease ; 
they vomit even before or after their breakfast, unless they swallow 
raw whisky or brandy as soon as they wake. One great obstacle to 
" breaking off " the liquor habit, is this morning nausea. An intense 
occipital headache accompanies this disease, which resists all treat- 
ment based on subjective symptoms, but when we cure or alleviate 
the follicular disease, the headache leaves. Ladies are often so sen- 
sitive and disgusted by the hawking, and offensive breath, that they 
refuse to go into society and become morbid and hypochondriacal. 
The tongue is often thickly coated with a brown fur. This, with 
the offensive breath, and intensely bitter taste in the mouth, give 
both patient and physician the idea that it is caused by biliousness. 

Deafness is a common accompaniment of this disease, owing to 
the occlusion of the eustachian tubes. Children with follicular 
throat diseases are especially liable to scarlatina and diphtheria. I 
am inclined to the belief that it is contagious, and that susceptible 
persons who breathe the same air, or are brought in contact with 
such patients, may contract the disease. 

Treatment. — The two stages, the hypertrophic and atrophic, will 
not yield to the same treatment ; we must select our internal and 
topical remedies to suit the pathological condition, not the subjective 
symptoms. 

Iodine approaches more nearly the ideal similimum for follicular 
diseases of the pharynx and contiguous passages, than any other 
drug. The medicinal disease caused by it runs through the same 
stages, and has similar complications. A large proportion of cases 
can be treated successfully by iodine alone, the 3x or 6x.internally, 
and a five or ten per cent solution in glycerine locally applied with 



DISEASES OF THE RESPIRATORY SYSTEM. 249 

a brush or injected through the nose. Next in value is the yellow 
iodide of mercury. The Symptomen Codex, the first Materia Med- 
ica of our school except Hahnemann's, published in this country, 
contained an excellent article by Dr. G. W. Cook, on this drug. He 
pointed out with great accuracy the condition of the throat, wherein 
iodide of mercury was curative, and the symptoms he gave are almost 
identical with those of pharyngeal follicular disease. 

The red iodide of mercury (mere, biniod.) is more suitable for 
the severest forms of the disease, when the neighboring glands (sub- 
maxillary, cervical, etc.) are affected, and the malady has a syphil- 
itic origin. 

Iodide of arsenic is next in value where the disease has followed 
a violent acute influenza, or scarlet fever, and the secretions are very 
acrid and offensive. (Phytolacca, arum, nitric acid, and nitrate of 
sanguinaria are congeners of iodide of arsenic, and can be used if the 
latter fails to change the disease within a reasonable time.) 

Iodide of gold, although it has not been proved or used by any- 
one but myself, has a very beneficial effect in the stage of atrophy, 
and especially when the bones of the nose appear to be affected. 
Iodide of silver ought to be equally useful when selected from the 
symptom of its two elements. 

Iodide of potassium was found by Dr. Meyhoffer to be specific 
when the iodide of mercury failed. He recommended it very highly 
for hypertrophic pharyngitis, and reports many cures of chronic 
cases from its use. Dr. Beverly Robinson declares that he never 
saw any curative effects from it, but that instead it always aggra- 
vated the disease. He says, " When taken for one or more days 
consecutively in moderately large doses, it will usually produce a 
very red and swollen condition of the mucous membrane of the air- 
passages. The nose will become so much stopped up as to interfere 
with normal breathing through the nasal fossae. Subsequently there 
is a considerable transudation of watery fluid from the vessels of the 
pituitary membrane, and increased discharge from the glandular fol- 
licles. The habitual symptoms of an acute attack of coryza are 
established, etc." 

Is it a matter of surprise that Dr. Robinson does not like iodide 
of potassium ? Does he suppose he can put out a fire by pouring 
oil on it ? He was using an exquisitely homeopathic remedy, and his 



250 THE PRACTICE OF MEDICINE. 

" moderately large doses," probably five to ten grains several times 
daily, could do nothing else than aggravate a disease so nearly like 
its own poisonous effects. 

Dr. Meyhoffer used the dilutions from the lx to 3x. His doses 
were not strong enough to aggravate, yet strong enough to set up a 
curative process in the diseased tissues. 

Iodide of lime is an excellent remedy when the disease occurs 
in fat lymphatic children, with swollen submaxillary and cervical 
glands. 

Iodide of sulphur is superior to sulphur alone ; and iodide of 
barium is indicated when the glands of the neck are swollen, hard, 
and threaten to suppurate. 

After the iodides, I place most reliance on cubebs, copaiva, thuja, 
Phytolacca, bichromate of potassium, hepar sulphur, and hydrastis. 
They are all capable of producing a diseased condition closely resem- 
bling the one under consideration. 

Cubebs is valued very highly by Dr. Robinson, who is not con- 
tent to give it in medicinal doses, but must needs saturate the system 
until the stomach, urinary organs, and skin suffer from its effects. 
Yet he declares he cures more cases with this drug than with any 
other. He prefers the pulverized cubebs. He says the oil and oleo- 
resin disappoint him. The homeopathic indications for its use are 
the tenacious, stringy, offensive, yellow or green discharge, the hyper- 
trophic mucous membrane and follicular glands, and the clinging 
character of the mucus. It does not cause ulceration like bichrom- 
ate of potassium, or erosion and atrophy like hydrastis. My expe- 
rience accords with that of Dr. Robinson. The tincture is useless, 
and the dilutions of the oil and oleo-resin not much better. I prefer 
a trituration of very finely ground cubebs, ten to twenty per cent, 
with granular sugar of milk. It acts much better when laid upon 
the tongue than when taken at once into the stomach. I order ten 
to twenty grains every three or four hours, continued for several 
days or weeks, until improvement is decided. At the same time I 
have this same powder snuffed up the nose, or thrown in with a pow- 
der blower so that it will reach the posterior nares. 

Copaiva is rarely indicated, but is useful when the discharge is 
muco-purulent and appears to run into the fauces from some cavity. 
It runs down from the posterior nares so rapidly and in such quan- 



DISEASES OF THE RESPIRATORY SYSTEM. 251 

tity that it causes nausea. The throat is not highly inflamed, but 
feels rough and raw. 

Thuja is not so highly valued as it should be in catarrhal folli- 
cular disease. It has more " hawking " of tough tenacious mucus, 
with soreness, rawness, and other painful symptoms, than the path- 
ogenesis of any other drug. The sphere of the drug corresponds to 
this disease, and I am surprised at its neglect. I paint the diseased 
surfaces with a ten per cent glycerine solution, and spray the poste- 
rior nares with it. 

Bichromate of potassium is so favorably known that I need not 
give the indications. My former pupil, Dr. C. A. Williams, of Chi- 
cago, has had unusual success with it. He gives the 3x internally, 
and applies a solution of one grain of the crude drug to one ounce 
of glycerine and water. He advises it in all stages, and even in 
ozseena. 

Chromic acid is not much used, yet I have had good results with 
it. During one winter when the influenza was prevalent in this city, 
a great many people were left with a peculiarly severe granular 
pharyngitis which seemed rebellious to ordinary treatment. Know- 
ing the value of chromic acid in follicular and granular endocervic- 
itis, it occurred to me that it ought to be of equal value in this dis- 
ease. In order to test its value I selected a few of the worst cases. 
After removing the secretion from the pharynx I painted the sur- 
face with a one per cent solution in water, ordering the patient not 
to swallow for a minute or two. This was applied every day for a 
week. Improvement set in at once, and all the cases recovered in a 
short time. In a few cases I have used a ten per cent solution, 
but made only one application every five days. Care should be 
taken that none of the solution is swallowed. 

Phytolacca more clearly resembles the preparations of iodine than 
any other vegetable drug. It ranks with iodide of potassium, iodide 
of mercury, and iodide of arsenic. It is particularly indicated when 
there is great soreness and lameness of the internal muscles of the 
throat and tongue, and a raw, contracted, stuffy feeling in the 
swollen pharynx. 

Hydrastis has won much popularity in post-nasal and pharyngeal 
catarrh. It is as much indicated in the follicular as in the catarrhal 
disease. It is of most value when applied topically, but enough will 



252 THE PRACTICE OF MEDICINE. 

be swallowed to get its admirable tonic effect on the stomach. It 
should be injected or sprayed through the nose, and used as a gar- 
gle. The non-alcoholic preparations should be used. They are 
made from the yellow and white alkaloids, and are called "fluid 
hydrastis " and "fluid hydrastin." A ten per cent solution of these 
fluids should be used. An elegant preparation is made by adding 
eight grains of the white alkaloid to eight ounces of distilled water, 
with half an ounce of glycerine. The yellow preparation stains 
badly, and is objected to ; the white alkaloid does not stain. 

Oil of sabal (saw palmetto) is an excellent remedy in both 
stages of follicular disease. It can be used in an atomizer, a two 
per cent solution in albolene or liquid vaseline, thrown up the nasal 
passages ; or a ten per cent trituration in sugar, placed on the 
tongue and slowly dissolved. Besides its curative local action, the 
oil acts as a prevention of catarrhal dyspepsia, and increases the 
assimilation of food. 

Aristol, two drachms to the ounce of albolene, used as a spray, 
removes the foetor in atrophic rhinitis more effectually than any 
other drug, except peroxide of hydrogen. Prof. W. A. Dunn, in a 
lecture on this disease, said, " In the atrophic type, the cardinal 
principle is antisepsis and stimulation. In this form you will find 
the greatest service from such remedies as sulpho-carbolate of soda, 
Dobell's solution and glycerine, combined with some active remedy, 
such as the glycerite of tar, tannic acid, or some other stimulating 
remedies. 

"In the hypertrophic type, it is the intention to favor nutri- 
tion and secretion. In this form you will find the most relief from 
soothing and astringent applications, such as the glycerite of euca- 
lyptol, hydrastis, and other remedies of this class, combined with 
albolene or benzoinol. In the hypersesthetic type, no local appli- 
cation should be used under any circumstances, as the tissues 
are so over-sensitive that local means only increases the irritation. 
[I can hardly agree with this last assertion, for I have found 
that a two per cent solution of cocaine or resorcin does relieve and 
soothe.] 

" Any preparation of petroleum, which is perfectly bland, non- 
irritating, and a most excellent menstruum for eucalyptol, hydrastis, 
calendula, or other remedy of this type, is especially serviceable in 



DISEASES OF THE RESPIRATORY SYSTEM. 253 

the hypertrophic type, as a remedial and soothing application com- 
bined. 

"The glycerites of tar, hydrastis, and eucalyptol are serviceable 
in the atrophic type of catarrh, to stimulate secretion and bring 
about a more active nutrition of the parts. It is essential, how- 
ever, before beginning the treatment, that all deposit be thoroughly 
removed before the remedial drug is applied. This can be best 
accomplished by sulpho-carbol, or Dobell's solution. The antiseptic 
tablets after my formula (sulpho-carbol, one grain ; hydrastine, 
white alkaloid, 1-150 of a graiu) are serviceable for removing the 
mucus, and also for medicating the mucous membrane at the same 
time. 

" The most desirable method of applying the solution is with my 
modification of the Davidson's atomizer. It is desirable to have the 
application applied to the posterior end of the nose, behind the soft 
palate, and the usual curved tip supplied with the atomizer is not 
long enough to go behind the soft palate when it contracts. This is 
overcome by a long tip with two openings, allowing a double spray, 
which is sufficient to wash away the tenacious mucus. 

"Applications to the anterior portion of the nose are of little 
service and do not properly reach the diseased membrane, as most 
types of catarrh are situated at the posterior end of the nose." 

Aluminum is useful in the atrophic naso-pharyngitis of old people. 

Penthorum ought to be useful in the incipient stage of the hyper- 
trophic variety. It has "fullness in the head, nose, and ears, with 
profuse discharge from anterior and posterior nares, and with a con- 
stant ' wet ' feeling in the throat, with rawness and stuffiness. It 
is an analogue of sticta, but the latter has symptoms of a more 
advanced stage. Its headache is more violent, and it has a dry, 
raw, sore, stiff feeling of the palate and pharynx." 

Wyethia has a similarity to both, but the raw, excoriated feeling 
is predominant, especially at the sides of the pharynx. 

On examining cases of pharyngitis, there will sometimes be seen 
one or more very red, raised, velvety patches, like the erosions found 
on the os uteri. On applying a weak solution of nitrate of silver 
(five per cent) with a brush, they will change to a healthy hue after 
a few applications made every three days. It should never be applied 
strong enough to cauterize. 



254 THE PRACTICE OF MEDICINE. 



HAY FEVER. 

Definition. — Hay fever, or catarrhus aestivus, is defined by Kip- 
pax as a" miasmatic disease, caused mainly by the action of the 
pollen of plants and grasses upon the organs of respiration "; by 
others as a " neurosis, having its seat in the nasal and respiratory 
muccus membranes." It is supposed by some pathologists that cer- 
tain persons have in their nasal passages certain " sensitive areas " 
which connect with the nerve centres in the medulla, and that when 
these are irritated by any foreign substance the disease is excited. 
It has been maintained that in certain persons this disease will 
appear when the vital forces are low, irrespective of any local irri- 
tation. 

It is a curious fact that hay fever is confined almost wholly 
to the educated classes, attacking professional men, and delicate, 
sensitive women ; its victims are mainly among the Anglo-Saxon 
races, in temperate climates ; it is rarely if ever seen in the South- 
ern United States, and never in the tropics. It attacks its victims, 
generally those between the ages of fifteen and forty-five, annually, 
during the months of June, July, August, and September. It appears 
suddenly, often the very day or hour at which it appeared the year 
before, and lasts about six weeks, leaving behind it no perceptible 
effects. It is hereditary in some families. The belief that it is 
caused by the pollen of certain plants has not yet been proven 
beyond doubt. If pollen be the cause, why is any race or country 
free from it, for there are nervous people all over the world, and 
pollen is universal. The rule that relief from the disease is gained 
by a residence in certain high altitudes, would seem to favor the 
pollen theory. The White Mountains, the Adirondacks, the Island 
of Mackinaw, the shores of Lake Superior, and a few locations in 
the Alleghany and Rocky Mountains, are said to be free from it. Dr. 
Blakely's experiments and investigations, apparently showing that at 
a certain height above sea-level pollen is not found in the air, would 
favor the pollen theory. Admitting all this, there must be an 
abnormal condition of the nervous system, manifested by sensitive 
nerve areas in the respiratory mucous membranes, which allows the 
pollen to exert its irritant effects. There are two forms of the dis- 



DISEASES OF THE RESPIRATORY SYSTE3L 255 

ease, the catarrhal and the asthmatic. The catarrhal form has all 
the symptoms of a violent influenza — namely : violent paroxysmal 
attacks of sneezing, with a thin, watery, acrid discharge from the 
nose ; redness of the conjunctiva, swelling and redness of the eyelids, 
and profuse lachrymation. There is a burning and smarting in the 
eyes, nose, pharynx, larynx and bronchi. In some cases, one of 
which is my own, it attacks only one side of the head, one eye, and 
one nostril. This would seem to be a proof of its neurotic nature. 
The experiment has been tried of causing it by having the subject 
smell an artificial rose. It caused an attack in those who believe a 
rose to be the exciting cause. 

The asthmatic variety is in addition constantly accompanied by 
a laryngo-bronchial catarrh, which sometimes attends, at other times 
follows, the naso-pharyngeal irritation. The asthmatic attacks gen- 
erally occur during the day, and are accompanied by a violent, irri- 
tating, almost spasmodic cough. 

Treatment. — Thousands who have the means go to some region 
known to give relief, but there are many who canuot leave their busi- 
ness without great sacrifices. For such there should be some pre- 
ventive treatment. I have found that, beginning a week or two 
before the expected attack, if the iodide of arsenic be given in doses 
of the 1-100 or 1-1000 of a grain three times a day, the disease does 
not appear. It has been reported that the same results have fol- 
lowed the use of Fowler's solution of arsenic, one to three drops, 
three times daily. The double iodide of mercury and potassium in 
the 6x trituration, and the arsenite of quinine, are said to be pre- 
ventive. Quinine in doses of five grains three or four times a day 
has been used with alleged good results. 

Dr. Alex Eixa ("Therapeutic Gazette," January, 1891) reports 
that he prevented the appearance of hay fever in six cases by means 
of the following treatment : Two weeks before the expected annual 
attack he had the patient irrigate the nose with a warm solution of 
common salt four times a day ; and a few minutes after each irriga- 
tion the nares were sprayed thoroughly with peroxide of hydrogen 
and glycerine, equal parts. This was repeated every day until the 
time of the expected attack. Three days before, he gave them five 
grains of salol and five of phenacetin three times a day, continued 
for a week. In two of these cases, although there were no nasal 



256 THE PRACTICE OF MEDICINE. 

symptoms, about two weeks after the expected attack some asthmatic 
symptoms appeared. He believes the peroxide of hydrogen acts on 
the germs that excite the disease, and destroys them. He does not 
believe with Sajous and McKenzie that there are any "sensitive 
areas," because he could not find them in any well developed case. 

In the December number of the "Therapeutic Gazette," for 
1892, Dr. Rixa claims to have found a specific for the hay asthma, 
which he could not prevent by the oxygen treatment ; this remedy is 
terpine hydrate. " In small doses (two to five grains) it liquifies and 
increases the secretion of the bronchial mucous membrane and facil- 
itates expectoration. In large quantities (fifteen to twenty grains) 
it reduces the secretion and renders expectoration less, until it stops 
altogether. In cases of bronchial dyspnoea consequent upon the 
plugging of the bronchi by a too copious secretion, it is of the great- 
est value." This shows us how differently large and small doses 
act in the suffocative catarrh of children. I have given the lx trit- 
uration with better results than I get from ipecac, sambucus, or 
stibium. During the course of the disease I have known naphthaline, 
in all doses, from five grains of the crude drug to the 3x trituration, 
to terminate the severity of the symptom in a few days. Its internal 
use can be aided by a spray of the one or two per cent solution in 
albolene or benzoinol, or even in water ; chloroform water, 1 to 1000, 
is an excellent vehicle. The iodides of arsenic, gold, and potassium 
will often entirely cure the nasal and pharyngeal symptoms in a short 
time. A spray of peroxide of hydrogen can be used at any time, 
as can also carbolic acid, hydro-naphthol, benzo-naphthol, thymol, 
and that excellent compound " thymo-hydrastis." Some interesting 
experiments have shown that a mixture of several antiseptics is as 
powerful against germs as the sum of all their separate antiseptic 
powers. 

I have never seen any decided good results from aconite, allium, 
ammonium, aralia, arum, euphrasia, lachesis, or sulphur ; but I have 
seen good effects from bromide of camphor, sticta, ambrosia, and 
nitrate of sanguinaria. Sabadilla is an unrivalled remedy for the 
spasmodic and paroxysmal sneezing (in the morning) with only slight 
catarrhal discharge. 

The asthmatic condition, ipecac, grindelia, quebracho, arsenite 
of copper, and euphorbia pilulifera will greatly palliate if not 



DISEASES OF THE RESPIRATORY SYSTEM. 257 

remove, but they must be given in appreciable doses, ten to twenty 
drops of the tincture every few hours (arsenite of copper 3x). 

The dry, harassing cough which often attends the first stage, 
destroying the patient's rest and sleep, can generally be controlled by 
doses of hyoscyamus lx, or hyoscine hydrobromate, 1-500 of a grain. 
Large doses of chloral hydrate produce an array of symptoms closely 
imitating hay fever. In several instances I have thought that its 
use in small doses cut short an attack. It is especially useful when 
conjunctivitis is present, and when the serous acrid discharge from 
the nose runs down the posterior nares and causes such constant 
hawking as to prevent sleep. In my own case I suffered greatly 
from these symptoms, and never found any remedy for them until 
I took five grains of chloral every hour. After the fourth dose I 
fell asleep, and did not awake until nearly morning, when I found 
to my surprise that the thin acrid discharge was replaced by a bland 
thick mucus, and a few days afterwards the catarrhal symptoms 
disappeared. This has since been the invariable result of its use in 
nearly every case in which I have prescribed it. 

Antipyrin, in some people, causes symptoms much like chloral, 
and there have been many cases reported in medical journals where 
it is said to abort the disease. Phenacetin is of decided benefit 
when the chief suffering appears to be in " the bones of the head 
and face." The seat of pain is probably in the frontal sinuses and 
the antrum. Mercury, iodide of potassium, and aurum are the home- 
opathic remedies for the inflammatory action in these cavities, and 
should be alternated with phenacetin. If the latter fails to relieve 
the pain, codeine, one-fourth to one-half a grain, can be given. At 
one time cocaine was largely used in the form of spray or injections 
into the nasal cavities. It relieves the fulness and swelling of the 
mucous membrane very quickly, and for a time allows easy breath- 
ing through the nose, allays the pain caused by the obstruction, and 
permits the patient to sleep, if the spray (two per cent) be repeated 
every two hours. Lately there has been a reaction against the use of 
cocaine. It is said that the cocaine habit is acquired by its absorp- 
tion, and that the drug exerts an insidious influence over the brain ; its 
magical palliative effects are a temptation to use it too often. 
Another objection to its continued use, is the increased sensitiveness 
and irritability of the mucous surfaces. 



258 THE PRACTICE OF MEDICINE. 

I have used resorcin, one per cent solution, with better ultimate 
results, as it has some of the anaesthetic effects of cocaine ; it reduces 
the swelling of mucous surfaces, and possesses considerable germ- 
icidal qualities. 

COUGH. 

The belief of the laity, and possibly of a good many in the med- 
ical profession, is, that all coughs arise from some portion of the 
respiratory tract. The fact is, however, that there is hardly any 
portion of the body which may not excite a cough. 

A cough, according to Landois, consists in a sudden violent expir- 
atory explosion, after a previous deep inspiration and closure of the 
glottis, whereby the glottis is forced open and any substance, fluid, 
gaseous or solid, in contact with the respiratory mucous membrane 
is violently ejected through the open mouth. This act, as we all 
know, is voluntary or involuntary ; voluntary in so far as we can 
produce the act at pleasure, and involuntary or reflex in that a point 
is often reached in bronchial irritation or from any other cause 
whereby, with all our will power, we are unable to stay the act. 
Kohts, in Landois' " Physiology," has located a coughing centre a 
little above that of the inspiratory centre in the medulla oblongata. 
According to this experimenter, the afferent paths are the sensory 
branches of the vagus, and the efferent lie in the nerves of the mus- 
cles of expiration and of those that close the glottis. That there are 
other paths there can be no doubt, as can often be seen from clin- 
ical experience ; though by far the largest amount of work is done 
by the latter nerves. So important is the par vagum in our cough- 
ing miseries, that the refreshing of our minds with the anatomy of 
its sensory branches will not be amiss. 

Dr. Learning, of New York, has well said, " The par vagum is a 
chummy, friendly nerve. It is the source of all our friendships. 
We dine together, meet together, drink together by its influence." 
The pneumogastric or tenth cranial nerve has its origin from a 
nucleus in the medulla oblongata along the ninth and eleventh nerves, 
and passing forward, it leaves the cranium through the jugular for- 
amen, being enlarged at the latter point into what is known as the 
jugular ganglion. Its main sensory branches, and hence those most 
involved in cough and most important to us, are as follows : 



DISEASES OF THE RESPIRATORY SYSTEM. 259 

" (1) The auricular branch, coming off from the jugular ganglion, 
receiving connecting branches from the glossopharyngeal or ninth, 
crossing the facial and giving sensory branches to the posterior 
portion of the auditory meatus and the adjoining part of the outer 
ear. 

(2) The pharyngeal plexus is aided in its formation by branches 
from the par vagum and from the ninth. From this plexus sensory 
branches supply the soft palate, arch, and probably the posterior por- 
tions of the inferior turbinate bones. 

(3) The superior laryngeal, the sensory nerve to the base of the 
tongue, and all the mucous membrane of the larynx, is pre-eminently 
the nerve of cough. 

(4) The pulmonary branches of the vagus join the anterior and 
posterior pulmonary plexuses, and hence, from this source, supply 
sensory (cough exciting) fibres to the whole bronchial system, lungs, 
and pleurae. 

(5) The sensory fibres to the stomach and also to the liver, and 
through connections with the great solar plexus, probably send fibres 
to the organs of generation. 

" From this brief anatomical exposition, we see from what sources 
irritations may come in producing cough, and being thus fortified in 
our knowledge we are better able to seek the proper source. The 
character of a cough depends largely upon the locality and nature 
of the cause of which it is a symptom. For we must bear in mind 
that we are not discussing a disease, a distinct entity, but a symptom 
of a disease or morbid state, and it is the latter condition which 
determines its character. Various words have been used as descrip- 
tive of peculiar kinds of cough, and it is well for us to pause for a 
moment and consider in our minds the meaning of such adjectives 
most frequently used, as brassy or metallic, hoarse, spasmodic, jerky, 
hacking, croupy, rasping, etc. 

" When we speak of cause in relation to cough, we of course 
mean those pathological conditions with which it is associated, by the 
removal of which the cough ceases. We cannot say that enlarged 
faucial tonsils always produce a cough, but that they are sometimes 
a casual factor we must admit, since a persistent cough often eases 
upon the removal of these organs. Hence, in this article, we shall 
try to consider all those factors which, in the light of clinical expe- 



260 THE PRACTICE OF MEDICINE, 

rience, have been found to aid in the production of this symptom. In 
all diseases of the lungs and pleura cough is a prominent symptom, 
but to discuss the diseases of these organs would extend this paper 
beyond a reasonable length ; so that, with the exception of a passing 
remark, the points of the article will be confined to the respiratory 
tract above the bifurcation of the trachea. To classify causes with 
distinct lines of demarcation is difficult indeed, but simply to aid us 
in the study, I have made the following arrangement : 

" (1) Causes dependent upon an acute pathological state of the 
respiratory tract, as (a) Lungs and Pleura ; (b) Larynx and Tra- 
chea; (c) Pharynx. 

" (a) Lungs and Pleura. — In all acute and chronic diseases of the 
lungs and pleura, cough is a prominent symptom, as one would 
naturally expect from the anatomical distribution of the pulmonary 
plexus. How familiar to many of you is the short, dry, jerky cough, 
with the accompanying stitch in dry pleurisy ? How, also, the deep 
basilar cough of pneumonia ? With a pulmonary cough there is 
usually the accompanying expectoration, sometimes labored and 
even requiring several efforts before it succeeds, while in pleurisy 
there is nothing to eject, and, consequently, the cough is dry and 
hacking. In acute and even chronic bronchitis, cough is one of 
the most distressing symptoms, and one which causes the patient 
many a sleepless hour. The accumulation of secretions in the bron- 
chial tract is often the most irritating factor, for we note how aggra- 
vated a cough is in the early morning hours before the expulsion of 
the secretions which have accumulated during our sleeping moments. 
Who has not seen this, the most distressing symptom, in phthisis 
pulmonalis ? Cavities in the lungs are always exciting factors, for 
it is here that the dirty, purulent secretions find a never-ceasing- 
abode. Dr. Learning, of New York, has recently called attention to 
the first paper of Dr. G. P. Cramman, in which the latter dwelt upon 
the management of lung cavities by position, thus showing how one of 
the most harassing symptoms of this dreaded disease could be alle- 
viated. The idea is based upon the fact that if you make the patient 
lie so that the cavity can be thoroughly emptied by cough and grav- 
ity, and he then be made to turn back, allowing an interval for its 
refilling, he can in this way secure at night several hours of needed 
rest. If the cavity is not thoroughly emptied, the constant running 



DISEASES OF THE RESPIRATORY SYSTEM. 261 

over, as it were, from the mouth of the reservoir acts as a continual 
source of irritation. 

" (b) Acute Inflammation of the Larynx and Trachea. — This con- 
dition has, as one of its commonest symptoms, cough, either dry or 
moist. The congestion thus occasioned by the inflammatory state, 
together with the increased amount of the secretion usually present 
with it, acts as an irritant to the nerve terminals in this locality. Upon 
this theory, therefore, the richer a portion of the tract is in nervous 
supply, the more irritable it will be and the more harassing and per- 
sistent will be the cough. Physiologists tell us that a cough cannot 
start from an irritation in every portion of the respiratory tract, but 
that certain areas only are supplied with nervous irritability. These 
are the glottis respiratoria and the bifurcation of the trachea ; other 
portions, they say, as, for example, the true vocal bands, are more 
or less insensitive. These facts are based exclusively upon the exper- 
iments of Kohts and Vulpian. Theoretically, this may all be true ; 
but practically we know that cough comes from irritation in any 
portion of the tract, and in inflammatory conditions we cannot 
limit this state to any circumscribed area. The character of a cough 
originating in the larynx and trachea is determined by the character 
of the existing pathological state or the anatomical formation of the 
region, according to the age of the individual. The tone of all 
coughs is modified by the condition of the larynx, and especially 
that of the true vocal bands, whether there be true oedema, or exu- 
dative material upon their surface. If, with a croupy cough, there 
is free expectoration, how much more favorable is the prognosis 
than when the exudation is membraneous and clings with deathlike 
tenacity to the surrounding parts. 

" The treatment of this symptom is but the treatment of the dis- 
ease, the main object being to lessen the hyperemic condition of the 
mucous membrane. All remedies for cough originating from this 
region are given to act locally, whether administered internally to 
be eliminated through the respiratory tract, or applied directly by 
means of inhalation, a method much the surer. I will not stop to 
mention all the remedies which have been brought forward as spe- 
cifics for cough due to this pathological state, but will allude only 
to those that have proven of most value in my hands. I dislike 
always to administer any form of opium if it can possibly be avoided, 



262 THE PRACTICE OF MEDICINE. 

and for this reason I use an inhalation treatment almost entirely. 
Dr. Bishop, of Chicago, a few months ago, advocated the use of a 
spray of menthol-camphor for various laryngeal troubles, and since 
that time I have used the remedy with marked success in laryngeal 
and tracheal coughs. While Dr. Bishop first called attention to the 
mixture of camphor-menthol, Dr. Hobbs, of Atlanta, was the first 
to bring prominently before the profession the use of both menthol 
and camphor in the treatment of nasal diseases. Triturate together 
equal parts of camphor and menthol, forming a deliquescent mass, 
and of the mixture make a one to four per cent solution in albolene, 
and with a suitable oil spray producer allow the patient to inhale it 
three or four times daily. Another remedy I have used with suc- 
cess is a mixture of terebene in vaseline oil (one drachm to two 
ounces) , inhaled in the same way as the first. In a cough accom- 
panying a severe laryngitis* the compound tincture of benzoin, 
given by hot steam inhalation as recommended by Lennox Browne, 
of London, is a most valuable remedy. 

" (c) Pharynx. — In acute follicular pharyngitis, cough is some- 
times present, due to the unusually irritative character of the folli- 
cles as the current of air strikes its surface. The treatment consists 
in the thorough destruction of the follicles, best done with the gal- 
vano-cautery point, followed with astringent applications of nitrate 
of silver. 

4i (2) Functional, or such as are dependent upon pathological 
states or deranged functions, more or less chronic : as (a) Nasal ; 
(b) Pharyngeal ; (c) Laryngeal ; (d) Aural ; (e) Gastric ; (f) He- 
patic; (g) Reproductive. 

" (a) Nasal. — All physicians who have worked to any extent in 
the nasal cavities know how frequently cough is excited when the 
mucous membrane covering the turbinates is touched with a probe. 
I have a little patient upon whom a violent fit of coughing is pro- 
duced whenever a spray is used in the anterior nasal fossse. This, 
of course, is reflex irritation but for a moment, and ceases when the 
spray is removed, but what we see here as a momentary cause 
becomes a continuous one in enlarged turbinates or in septum spurs. 
Dr. Beverly Robinson, of New York, speaks of coughs of this char- 
acter as due to posterior hypertrophies of the inferior turbinate, pro- 
ducing pressure and irritation by contact with the septum. Some 



DISEASES OF THE RESPIRATORY SYSTEM. 263 

rhinologists have found certain areas in the nose more sensitive than 
others. Dr. John MeKenzie, of Baltimore, found in the posterior 
portions of the inferior turbinate the most irritable area, while Mr. 
Lennox Browne, quoting Hack, found it in the anterior portion. 
Nasal neuroses, dependent upon abnormalities in the nasal cavities, 
have of late taken a prominent place as casual factors in producing 
many symptoms before unknown. That such abnormalities play an 
important role, no one can deny who has seen the benefits accrue to 
patients relieved of these morbid conditions. Deviated septums, 
spurs, enlarged or hypertrophied turbinates, polypi, etc., can all, by 
reflex irritation, be a cause of cough, hence it behooves a physician 
to examine thoroughly into the nasal cavities when no discoverable 
lesions can be found elsewhere as a casual factor in the production 
of this symptom. To go into the methods of treatment of the dif- 
ferent forms of nasal diseases that cause cough would make a lengthy 
article of itself ; suffice it to say that every source of possible irrita- 
tion should be found and removed. Hypertrophies are best removed 
with the galvanic cautery, and polypi should be thoroughly extir- 
pated with the wire ecraseur. All septum deviations and spurs, 
when prominent enough to be a source of irritation, should be 
removed by whatever method the operator chooses. Naso-pharynx 
adenoids, besides an obstacle to free nasal breathing, are sometimes 
an active source of coughs, as is also an enlarged third or pharyngeal 
tonsil. The pharyngeal tonsil is a collection of lymphoid tissue, usu- 
ally in the median line of the vault of the pharynx, and while often 
overlooked, it is frequently the source of a post-nasal catarrh, and a 
causal factor in the production of the symptom in question. If a 
patient be examined with a post-rhinal mirror, this globular, red, pro- 
truding mass will be seen in the vault, and, in the majority of cases, 
coated with ropy mucous secretion. The only permanent cure for 
this condition is the complete extirpation of the offending masses, 
best done with some post-nasal forceps. Adenoids should always be 
removed as soon as possible, that the attending train of symptoms 
may be eradicated. 

" (b) Pharyngeal.— An elongated uvula is another source of cough, 
and must not be overlooked, its character being of a hacking nature 
without expectoration. I dislike to mention the uvula as a causal 
factor, from the fact of its abuse and the rough treatment it has 



264 THE PRACTICE OF MEDICINE. 

received at the hands of many physicians. How often has a poor, 
innocent little, slightly elongated uvula been clipped, when no other 
cause for a cough could be found, and the patient thus made to 
suffer the inconvenience of an incomplete closure of the post-nasal 
space in deglutition. One must observe whether the uvula is relaxed 
or falls with ease upon the base of the tongue before looking upon 
it as a source of irritation. Cough due to this cause is most trouble- 
some at night when the patient is lying down and the organ falls 
against the pharynx. The treatment consists in the reduction in the 
size of the organ, either by medicament, or ablation of a portion. 
Astringents should always first be tried, and, these failing, provided 
the length warrants, abscission can be performed, usually with suc- 
cess. One unaccustomed to the performance of the operation will 
invariably incise too much and leave the patient in a more uncom- 
fortable state than the one previous. A large portion of the uvula 
being muscular, it has a tendency to contract, so that its muscular 
portion should not be cut. In the majority of elongated uvulae, one 
will always see between the mucous membrane and the muscle a dis- 
tinct line of demarcation, and it is here that the line of clipping 
should be made. Long forceps and scissors are all that is required. 
Do not cut off too much, if you do not want the unsavory benedic- 
tion of your patients. Hypertrophied faucial tonsils, while not fre- 
quent, is sometimes the cause of a persistent cough, especially in 
children. Dr. Beverly Robinson, of New York, makes mention of 
the fact, and Lennox Browne, in speaking of a neurotic cough, 
believes that there is always an objective cause. He says the com- 
monest of these is the irritation of enlarged tonsils, and cites two 
eases where the removal of these organs was followed by the cessa- 
tion of that symptom. He further says, ' Recent experience leads 
me, even where the tonsils are not enlarged, to suspect adenoid 
growths in all cases of reflex spasmodic cough. Adenoids and enlarged 
tonsils so commonly exist together, that a thorough inspection for 
both is always demanded.' Beverly Robinson says, ' Hypertrophy 
of this structure (tonsils and adenoids) gives rise to congestion of 
the lower naso-pharynx, and this increases the sensory excitability.' 
The treatment of this condition is the removal of the enlarged ton- 
sils by whatever method the operator chooses. McKenzie's tonsilo- 
tome is a favorite instrument with many, and has proven very satis- 



DISEASES OF THE RESPIRATORY SYSTEM. 265 

factory in my hands. The means matters little, provided they are 
removed. 

" Enlarged lingual tonsils. — The name tonsils, in this connection, 
is misleading, for the morbid condition rather signifies a collection 
of lymphoid tissue, lobulated in appearance, at the base of the tongue, 
especially at the sides. This lymphoid glandular tissue is sometimes 
the cause of a harassing, rasping cough, especially in singers or 
public speakers, among whom this condition is most prone to exist. 
So common is it among this class that I immediately look for it when 
singers consult me for treatment. Numerous mention has been made 
of this condition in the recent literature upon this subject. A» 
Ruault, in the 'Archives de Laryngologie,' as late as June, 1888, 
speaks of it, as does also Dr. J. W. Gleitsman, in the New York 
4 Medical Record ' for December, 1887. Associated with the cough 
is a feeling of constriction in the throat and the sensation as if a 
foreign body were present whenever the act of deglutition is per- 
formed. The treatment consists in its removal. If lobulated and 
large, it can be removed with the wire ecraseur ; otherwise, the occa- 
sional application of the galvano-cautery will be found more ser- 
viceable. 

" (c) Laryngeal. — Under this head must be mentioned the 
growths, whether external or internal, benign or malignant, which, 
by their presence, irritate some filaments of the superior laryngeal 
nerve, and cause cough. Removal of such growths will prove the 
only satisfactory treatment. The accumulation of a dirty, purulent 
secretion in the larynx, attendant upon an existing atrophic rhinitis, 
is frequently a source of irritation and productive of a cough, which 
is only removed by the cure of the nasal disease. 

" (d) Aural. — Cough from irritation of the auricular branch of 
the pneumogastric, is an occasional, though infrequent, occurrence. 
Many cases have been reported where the removal of impacted ceru- 
men, foreign bodies, etc., from the external auditory canal has 
relieved a cough of long standing. Such a case I saw a few weeks 
ago in that of a medical student, who had exhausted all the known 
remedies for his cough, only to experience relief when a large mass 
of impacted cerumen was removed. In the last edition of Dr. Roosa's 
work on * Ear Cough,' he quotes numerous authorities who hold the 
same view. The treatment consists in the thorough removal of all 



266 THE PRACTICE OF MEDICINE. 

abnormal substances from the external auditory canal, especially if 
they be present upon the membrana tympani. 

" (e) Gastric. — Gastric neuroses manifested by reflex irritations 
in other portions of the body are no uncommon occurrences, espe- 
cially in the work of the general practitioner. The anatomical rela- 
tionship to the great solar plexus of nerve makes the stomach a cen- 
tre from which many nerve impulses originate, and which may thus 
prove a centre for many reflex phenomena. The three great vital 
centres, the brain, heart, lungs, are greatly influenced by its morbid 
condition or any functional derangement of the same. A ' stomach 
cough ' is no infrequent occurrence with children. Flatulency, dis- 
tension, loss of tonicity, are some of the frequent concomitant symp- 
toms. Young children from under the watchful care of their mother 
frequently overload their stomachs with cakes, candies, fruits, etc., the 
result of which, manifesting itself at bedtime by an incessant cough, 
is quickly relieved by an efficient emetic or a good dose of oil. Indi- 
gestion plays no small part as a causative factor in this symptom, 
and hence a well regulated digestive apparatus is a matter of neces- 
sity as well as of comfort. 

" (f) Hepatic. — Organic rather than functional derangements of 
the liver are more apt to act as excitants of a cough. Alcoholic sub- 
jects especially are more prone to suffer from this symptom, whether 
they be suffering with a hypertrophic or atrophic cirrhosis of this 
organ. A case recently under my charge affords a typical example 
of the condition in question. A German, male, aged forty-five, was 
referred to me by his family physician on account of an incessant 
cough of the most explosive nature, which had yielded to no course 
of treatment. The patient gave a good family history, and to all 
appearances his present physical condition, save the cough, was 
excellent. By the habit, acquired in his fatherland, he was an 
excessive beer-drinker, with an occasional interspersion of more spir- 
ituous liquors. His pharynx was very sensitive to the least manipu- 
lation, and vomiting would be produced with the slightest provoca- 
tion. By degrees a thorough examination was reached. The nasal 
cavities showed nothing as a causal factor, and the pharynx, save 
the anaemic, soggy condition of the mucous membrane throughout 
the oral cavity which one usually finds in chronic alcoholics, pre- 
sented nothing abnormal. The retching would cause the epiglottis 



DISEASES OF THE RESPIRATORY SYSTEM. 267 

to appear unusually large, but when quiet was restored to the parts, 
no pathological changes could be seen within the larynx. I then 
turned my attention to the stomach and liver, and found him suffer- 
ing with a condition of chronic gastritis, and, by palpation and per- 
cussion, the liver was found to be much enlarged and hardened, with 
slight tenderness. Whenever firm pressure was made over the 
hepatic region, a paroxysm of coughing was immediately started. 
The morbid process had so far progressed that no remedies suc- 
ceeded in staying it. I doubt not that many of you have often seen 
a nervous, hacking cough, dependent upon an engorgement and tor- 
pidity of the liver, quickly relieved by some hepatic stimulant or 
mild cathartic. In malarious districts this condition is frequently 
an exciting factor, and a thorough regimen of treatment must be 
instituted before the symptoms will abate. 

" (g) Reproductive. — Before closing, I must mention a cough 
which is sometimes present about the age of puberty, seemingly 
dependent upon the condition of the reproductive organs or of the 
blood. In 'The Lancet' of December, 1890, Sir Andrew Clarke 
had an article entitled, ' Remarks on the Barking Cough of Pu- 
berty,' and cites several cases of this condition occurring in his 
practice, both in boys and girls. Dr. Learning, of New York, who 
has since called attention to this subject, has reported such a con- 
dition occurring in a young girl suffering from chlorosis, following 
an attack of mountain fever. The late Sir Morell Mackenzie has 
also reported such a case. That there is a close relationship between 
certain conditions of the reproductive organs and certain nervous 
phenomena in other portions of the body, no one, I am sure, will 
deny, for day by day appreciation of the correlation of our bodily 
functions is growing in importance. Dr. John McKenzie, of Bal- 
timore, has called attention to certain nasal conditions coexisting 
with a peculiar state of the reproductive organs, which, from their 
constancy, do not seem to be entirely fortuitous. In all cases the 
treatment must be general, the aim of the physician being to restore 
the body to as normal a condition as possible by rectifying all mor- 
bid states in individual organs." 

I do not propose to give the indications for all our medicines for 
cough. In no department of therapeutics is it so important to search 
for the cause, and prescribe for that, and not for the cough and its 



268 THE PRACTICE OF MEDICINE. 

sensations. An ovarian cough, for example, can be cured only by 
an ovarian remedy ; a hepatic cough, by a drug having an affinity 
for the liver. First, ascertain the original focus of irritation, then 
select a remedy having an elective affinity for that localitity, and if 
such a remedy is also indicated by the totality of the distinctive 
symptoms, it will cure promptly. Some of these reflex coughs are 
so violent, and demand such immediate relief, that we are justified 
in using palliatives, but we cannot expect to cure such a cough, 
unless we find the specific remedy. 



HYPERAESTHETIC PHARYNGITIS. 

Under this title Dr. Dunn calls attention to a class of cases 
which have come under his observation, in which serious reflex symp- 
toms have come from hyperaesthetic spots within the larynx. This 
orifice is as intimately connected with other portions of the system 
as are the other orifices of the body, and as frequently exposed to 
irritating causes. 

" Granular pharyngitis, or clergyman's sore throat, has been one 
of the frequently discussed diseases for many years ; like nasal 
catarrh and polypus, it is one of the diseases that has been known 
and abused for the past ages. 

" But three chronic diseases in this region have been generally 
understood by the laity : catarrh, nasal polypus, and clergyman's 
sore throat. These diseases, like liver complaint, covered a multi- 
tude of sins, and were all considered incurable. In recent years, 
with the careful diagnosis and the application of new methods of 
treatment, the diseases formerly specified under these three heads 
have multiplied into many." 

But little has been said, however, of the hyperaesthetic type of 
granular pharyngitis, and he is sure that it is most worthy of atten- 
tion. A little source of irritation may produce many and various 
results. " I have seen," he writes, " a small hyperaesthetic spot in the 
pharynx destroy the voice, produce spasm of the larynx, and undo 
the general condition to such a degree that permanent ill health was 
brought about. Patients suffering from the hyperaesthetic type of 
granular pharyngitis complain of continued irritation in the pharynx 
on one or both sides, with many types of reflex disorder. 



DISEASES OF THE RESPIRATORY SYSTEM. 269 

" One cannot sing from loss of voice, another complains of pain 
in the ear, another of hoarseness, another from general nervous irri- 
tation and hysteria, another with a cough, and so on the round of 
nervous reflexes. 

" On examining the throat there appears on the posterior wall 
the usual type of granulation. There may be one or many, but the 
most frequent hypersesthetic spot is on the sides of the pharynx 
behind the posterior pillar. As a rule a ridge of red, almost gran- 
ular tissue is seen extending upward behind the posterior pillar 
on one or both sides. This may be very small or as large as a pen- 
cil, and from one-eighth to one inch long. Sometimes, in touching 
this spot with a probe, the patient is attacked with a paroxysm of 
coughing, or a sense as if a foreign body was in the larynx or ear. 

"Asa rule, the disease is not attended by pain other than the 
reflex irritations. The throat is frequently inflamed when the gran- 
ulations become increased in size and more irritable. This con- 
dition begins, I believe, in a simple catarrhal inflammation which 
affects the glandules and arytenoid tissue in this region, producing 
a hyperaesthetic change and over-growth of tissues. In this increased 
growth is developed the over-sensitive termini of the branches of the 
recurrent nerves which supply this portion of the pharynx, and are 
so intimately associated with other parts of the system. The nerve 
ends become hyper-developed and extremely sensitive, and for this 
reason the tissues become over-sensitive to all irritation, both mental 
and physical. In some cases I have observed that mental excite- 
ment produced increased hyperesthesia of the throat and added 
much to the reflex irritation." 

Dr. Dunn gives a few illustrative cases to convey the idea of 
the serious result attending this disease. 

"Case 1. — Mrs. H., age thirty, and of extremely neurotic tempera- 
ment, had suffered for many years from general ill-health. She was 
poorly nourished, emaciated, and extremely nervous. She had been 
treated for uterine trouble, for rectal trouble, for catarrh, for dyspep- 
sia, for anaemia, and for many other diseased conditions, without good 
results. It had been impossible to find the source of irritation or to 
cure it. She was referred to me on account of some irritation of 
the pharynx that had been unsuccessfully treated by sprays and 
other usual applications for the throat. On examination I found 



270 THE PRACTICE OF MEDICINE. 

the pharynx to be dotted here and there by granular pharyngitis, 
while on each side of the pharynx posterior to the pharyngeal fold, were 
moderately developed hyperaesthetic granules. For these, I advised 
removal by electro-cautery, as it has been my experience that local 
applications to this type of trouble are of no avail. The result of 
the removal of these growths was truly remarkable. The patient 
immediately improved in general health, the appetite returned, the 
nervous irritability was relieved, and in a short time the patient had 
gained twenty pounds in weight and was restored to good health. 
It is difficult to appreciate how so small an irritation can so thor- 
oughly depress the general nervous system, and destroy the nutri- 
tion to such a degree as to produce a permanent state of ill-health. 
But when we bear in mind that this sensitive spot is a continuous 
thorn in the flesh, as it were, and in direct communication with vege- 
tative and the recurrent nerves, we can appreciate how such a condi- 
tion may be brought about. 

" Case 2. — A lawyer complained that on attempting to speak, his 
voice would suddenly become hoarse and devoid of pitch There 
was a sensation as if he must clear his throat, with a slight irrita- 
tion in the larynx. The hoarseness was a peculiar dullness of the 
voice. On examination of the larynx the vocal chords appeared per- 
fectly normal as well as the whole laryngeal fold. On the posterior 
wall of the pharynx could be seen two small hypertrophic spots, which, 
being irritated by the sound, produced exactly the symptoms of 
which he complained. This convinced me at once that they were the 
source of irritation and I advised their removal, which was done by 
the electro- cautery, and he has had no symptom of hoarseness recur 
for two years. 

"Case 3. — Mrs. J., a prominent actress, was obliged to abandon 
her engagement because of inability to produce certain tones and to 
sing in public. She complained that when appearing in public her 
voice was absolutely lost and she was unable to produce a tone. 
The pharynx and neck would become spasmodically and violently 
congested. The throat, including the thyroid gland, would become 
swollen externally ; in fact, she had lost all power over her voice 
when attempting to sing in public In the parlor, when no one was 
present, she had a moderate control of her voice, yet not perfect. 
An examination of her throat revealed a large hypertrophic and 



DISEASES OF THE RESPIRATORY SYSTEM. 271 

sensitive spot on each side of the pharynx, occupying the entire space 
behind the posterior pillar of the fauces. This I believed to be the 
source of her irritation and I removed it. The result was most per- 
fect, as the voice was restored to its former power and she was 
relieved of the spasms and irritation in the throat. In this case I 
am sure the nervous influences had much to do with bringing about 
the immediate spasm. The pharyngeal irritation was not sufficient 
to destroy the voice except under mental excitement, but the irrita- 
tion plus the mental excitement was sufficient wholly to destroy the 
voice and bring about the spasms and congestion of the whole throaty 
both externally and internally." 



ACUTE LARYNGEAL GEDEMA. 

In a recent lecture Prof. W. A. Dunn, of Chicago, said : 
" This condition is not very common and is but poorly under- 
stood, as a rule, by the general practitioner under whose observa- 
tion such cases come, and who, if not familiar with the condition, is 
liable to let slip the valuable moment when the patient's life may be 
saved. 

" It is very rarely observed that acute laryngeal oedema, accom- 
panied by a spasmodic closure of the larynx, occurs, yet I have seen 
a few cases of this type. A case lately came under my observation, 
in which an active laryngeal oedema had taken place, even to the 
point of suffocation. The man had taken cold three days before I 
saw him, and had had a moderate chill and fever. The pharynx 
was slightly inflamed, with an excessive secretion of mucus. He 
very soon developed difficult respiration which grew worse and 
worse. The patient was able only to vocalize in whispers, and the 
suffocation grew to be extreme. The secretion of clear, glairy mucus 
was very great, and his painful attempts to expectorate added to the 
suffocation. On examining the larynx I found the arytenoidian 
regions and the arytepiglottic fold very greatly swollen and cedem- 
atous. The larynx proper was not especially implicated, but the 
swelling was above the vocal chords, the left side being worse. I 
advised the sucking of particles of ice, together with apis and bella- 
donna, and the patient made a good recovery without accident. I 



272 THE PRACTICE OF MEDICINE. 

cautioned the family that on the slightest symptom of violent suffo- 
cation to notify the physician, who was to open the larynx. The 
great danger in such cases is the liability to spasm of the larynx, 
closing the small fissure that is left for respiration. 

" The excessive secretion of mucus produces more or less desire to 
cough and expectorate. The patient is liable to have an attack of 
coughing that will expel much of the residual air in the lungs, and 
at the end, the irritation produces a spasm of the larynx that closes 
the glottis entirely. This paroxysm is so sudden and so violent that 
everyone is taken unawares, and if the doctor or the attendant be 
not forewarned and prepared for such an emergency, the patient is 
apt to die before the spasm will be relieved. If the condition be 
secondary to some other local inflammation in the throat, we must 
bear in mind the original cause and relieve that as rapidly as pos- 
sible, in order to prevent increased accumulation in the larynx, but 
if the laryngeal condition assume alarming proportions, we must 
exert our energies toward relieving the symptoms of suffocation. 

" We must bear in mind that the indication is to restore the 
breath-way, either through the laryngeal opening or through the 
throat. The most desirable procedure is intubation, but if the at- 
tendant be not sufficiently skilled to perform this operation, the next 
resort is to open the trachea through the throat. This may be done 
with a single cut of a knife, and, under alarming circumstances, a 
pen knife, butcher knife, or any sharp instrument will answer the 
purpose. It is certainly unfortunate to stand by and see a patient 
die when the partition between the life-giving air and the lung is so 
thin. One should have no hesitancy in opening the trachea without 
regard to future results, because it is certainly better to be a live 
man without a voice than to be a dead man with the larynx whole. 

" The most dangerous part of such a procedure is the liability of 
destroying the voice by separating the thyroid cartilage, which would 
most certainly follow an unskillful and hurried tracheotomy. There 
is but little danger in opening the trachea under such circumstances 
if a physician can be secured soon after. The hemorrhage is liable 
to be very profuse, but can be stopped without danger and the tube 
afterwards inserted. Under any circumstances open the trachea 
before the patient is dead ; but even after life seems extinct the 
patient may be restored by the tracheotomy. 



DISEASES OF THE RESPIRATORY SYSTEM. 273 

" It is sometimes possible to relieve the spasm by placing the fin- 
ger in the larynx and elevating the epiglottis and forcing open the 
laryngeal opening. This can be hurriedly done, and if not success- 
ful, the trachea can then be opened. I carry in my operating case 
a pair of Schrotter's laryngeal dilators. This instrument is a large 
curved canula, which may be introduced into the larynx through the 
mouth and retained in position as long as necessary. With it I can 
open the larynx and restore the patient until the breathing is estab- 
lished, after which I can proceed to perform intubation or trache- 
otomy if necessary. 

" The greatest thing under such trying circumstances is to know 
what to do, to have the courage to do it, and to be on hand at the 
proper time. In a single moment a distinguished mind is gone, and 
with a single stroke of the knife it may be returned. Such is the 
experience of the skillful physician who holds life in his grasp." 

Several cases of oedema of the glottis have been promptly cured 
by apis and pilocarpine, the latter given in doses sufficient to cause 
salivation. 



THE TREATMENT OF NASAL STENOSIS. 

Prof. W. A. Dunn, M.D., of Chicago, in one of his lectures says : 

"There is no class of troubles more serious and far-reaching 

in its effects than the closure of the nasal and naso-pharyngeal pas- 



" If this condition occur early in life, the effect on the growth of 
the child is most remarkable, both as to constitutional and local 
changes. The violent effort of breath-taking produces changes in 
all organs pertaining to this physiological function, especially marked 
on the formation of the chest and face. 

" The thoracic walls are compressed by the inter-costal muscles 
at the points of attachment, while the other portions are forced out- 
ward by the violent efforts of breathing. The sternum is forced 
inward at the lower portion and at the top, while in the middle 
it is usually forced outward, making the condition known as pigeon 
breast. 

" The facial expression is markedly affected, because of the open 
mouth, the compressed nose, the drooping eyelids, the vacant expres- 

13 



274 THE PRACTICE OF MEDICINE. 

sion of the eyes, the pigeon breast, and the generally imbecile look 
of the mouth-breather. The effect on the development of the brain 
in these cases is very great. The child suffers from a continual 
reflex cerebral congestion, which is especially marked during sleep, 
when the breathing is much more difficult. Such cases are disturbed 
by continual dreams and nightmare. The effort at breathing 
becomes exceedingly violent and at times apparently suspended. 
The child starts with a gasp and a violent effort, and the breathing 
is reestablished. 

" Such a condition of cerebral irritation cannot fail to produce an 
unhappy result in the cerebral nutrition and growth of the brain and 
mental faculties. Such children suffer from mental depression, dull- 
ness of intellect, and general bad nutrition. 

"The causes of nasal stenosis are as numerous as are its serious 
results. They may be located in the nose, the naso-pharynx, or the 
pharynx. The nasal conditions are either congenital or acquired, 
and may have their origin on the facial or septal side of the nose. 
The congenital conditions are due to a mal-formed nose, in which 
that organ is narrow, pointed, and almost or completely filled by the 
turbinated bones. In such a nose there is often a narrow nasal ori- 
fice in which the alae are so closely coapted with the septum that it 
acts as a valve during inspiration, and in that manner causes the 
stenosis. In cases in which a partial stenosis is due to congenital 
causes, this often becomes in after life a complete stenosis from a 
moderate hypertrophy of the turbinated bodies, requiring operation 
later in life. 

" Deviated septums are frequent causes of congenital stenosis, 
but seldom require operations until later in life, when catarrhal 
hypertrophies cause an occlusion of the opposite side. Different 
types of simple and benign tumors are frequent causes of nasal sten- 
osis ; hypertrophies of the nasal tissue, the result of catarrh, nasal 
fracture, dislocation of the nasal cartilages, plastic adhesion of the 
posterior nasal tissue, and septal protuberances, each form their part 
in making up this long list of nasal stenoses. 

" The naso-pharyngeal conditions are arytenoid growths and 
other types of naso-pharyngeal tumors, which may be found in this 
region. 

" Adhesion of the soft palate to the posterior pharyngeal wall* 



DISEASES OF THE RESPIRATORY SYSTEM. 275 

from syphilitic or tubercular ulcerations, are not uncommon. Hyper- 
trophy of the tonsils is the most frequently observed pharyngeal 
condition producing mouth-breathing. 

"The treatment of all these classes of troubles resolves itself 
into one of surgical operation : Remove the growth with sufficient 
thoroughness to produce a normal breathway. It matters not what 
the condition, if the breathway be interfered with relief must be 
obtained, and the most important part is the diagnosis and the 
manipulative skill to perform the operation. Nasal hypertrophies 
should be removed with a snare or the scissors, the deformed nose 
should be relieved by removal of the turbinated bone, protuberances 
of the septum should be relieved with a saw, the deflected septum 
should be broken up and replaced, the fractured nose should be prop- 
erly restored and placed in splints, the plastic adhesion should be 
removed with the post-nasal forceps, polypi should be removed with 
the cold snare and the bases treated with the electro-cautery, malig- 
nant tumors should be thoroughly removed if not too far progressed, 
either through the nasal opening, or by dissecting up the lip and 
opening the whole nasal space. The arytenoid growths are best 
removed with the post-nasal curette, and tonsils should be excised 
with a properly selected tonsilotome. The electro-cautery in com- 
plete nasal stenosis is seldom of value. Like every other good instru- 
ment, it has had its enthusiastic stage and is now used for the most 
valuable results. It is seldom possible to remove sufficient tissue by 
the electro-cautery to restore properly the breathway except in those 
cases of chronic catarrh in which the enlargement of the turbinated 
bodies is due to a chronic congestion and not to a hypertrophic 
change. 

" The danger of operating in the nose is reduced to a minimum by 
skillful manipulation. No operation should be made without the 
parts being thoroughly under observation. 

" The use of the nasal drill and burrs, and the dental engine, I 
believe to be unnecessarily severe and unscientific. 

" With the saw, the scissors, the knife, the snare, tne electro-cau- 
tery, any of the usual operations can be easily and successfully per- 
formed. The most serious danger in nasal operations is hemor- 
rhage, which can be relieved only by proper plugging, whether 
anteriorally or posterially ; but with a properly applied nasal plug 



276 THE PRACTICE OF MEDICINE. 

through the anterior portion of the nose, serious hemorrhage seldom 
follows." 

EPISTAXIS. 

Definition. — Bleeding of the nose may be idiopathic or symp- 
tomatic, active or passive. It is idiopathic when no change can be 
discovered in the tissues of the nose. It occurs in the young, 
plethoric, and robust, and generally between the ages of ten and 
twenty. It is usually arterial, and is generally salutary, being 
nature's method of preventing cerebral congestion, or getting rid of 
an excess of blood. 

Epistaxis is sometimes due to a cachectic condition of the blood. 
It is common in those persons called " bleeders," who, owing to a 
constitutional tendency, bleed from any portion of the body, even 
the skin and sound mucous surfaces. It is sympathetic when caused 
by diseases of the liver, spleen, or kidneys. It often occurs at the 
age of puberty in both sexes ; and in girls it appears at the period 
when the menses should appear. In women it often precedes or 
takes the place of the menses, when it is called vicarious menstrua- 
tion. Mountain climbers have epistaxis when they reach a certain 
height, and travelers on railroads through and over mountains often 
bleed freely at the nose. When it occurs during typhoid fever, 
scarlatina, diphtheria, or small-pox, it is sometimes of grave import. 

Treatment. — Medicinal treatment is often sufficient. A resort 
to mechanical measures should be delayed as long as possible, for a 
sudden stoppage of the flow in plethoric or apoplectic subjects is 
dangerous to the patient. Aconite, gelsemium, and veratrum viride 
are sufficient when the state of the circulation calls for their use. 
They arrest it by decreasing the blood-pressure in the arteries. 
(Mother tincture or lx.) 

Belladonna, glonoine, mellilotus, crocus, millefoil, bryonia, and 
f errum are strictly homeopathic to active hemorrhage when the arte- 
rial pressure and dilation is above normal. (3x to 6x.) 

Arnica and bellis perennis arrests it when it is caused by a blow, 
concussion, or high altitudes. 

Bryonia, pulsatilla, sanguinaria, senecio, trillium, and coceulus, 
when it appears before, during, or at the menstrual period. 

Hamamelis, cardunus aurum, and collinsonia when it is venous 
and there is general or local varicosis. 



DISEASES OF THE RESPIRATORY SYSTEM. 277 

Aesculus, sepia, sulphur, nux vomica, aloe, and collinsonia when 
apparently connected with piles or portal congestion and hepatic dis- 
orders. When occurring in persons with the hemorrhagic diathesis 
(bleeders), the chief remedy is ergot (secale), which acts best when 
used hyperdermatically (ten to twenty drops of the normal tinc- 
ture, or cornutin solution) ; phosphorus, lachesis, china, and elaps, 
are also good. Ipecac has been known to arrest epistaxis, even in 
small doses. Erechthitis, erigeron, thaspi, cannabis indica, and tur- 
pentine have been used successfully in arterial hemorrhage. Tur- 
pentine, however, like ustilago and ergot, is also useful for passive 
hemorrhages when the blood is dark, thin, and grumous. 

Carbo vegetabilis appears to have some specific influence on pas- 
sive epistaxis, when the blood is not in a normal condition. 

Mechanical measures, such as cold to the head and back of the 
neck ; hot foot baths ; bending the head forward ; holding the arms 
above the head ; have all been useful. Injections of pure lemon 
juice ; dilute hamamelis, and a weak solution of chloride or per-sul- 
phate of iron have been used with success ; also a ten per cent solu- 
tion of antipyrin, with ten grains internally, or a saturated solu- 
tion on lint, pushed up to the bleeding surface, are said to have been 
successful. 

Guarana, twenty drops of the tincture every hour, cured an obsti- 
nate case. In a case of epistaxis during purpura, xanthium arrested 
it promptly after all other means failed. The expressed juice was 
injected up the nose. 

Lesions of the nostrils as a cause of epistaxis are sometimes over- 
looked. Two obstinate cases once came under my care, and on exam- 
ination I found a granular surface high up on the septum, which 
bled on the slightest touch. A fifty per cent solution of chromic 
acid was carefully applied, and the bleeding never returned. 

Polypi may cause profuse bleeding, which will cease only on their 
removal. 

LARYNGISMUS STRIDULUS. 

(Asthma of Millar. Child Crowing. Spasm of the Glottis.) 

Definition. — "A convulsive seizure limited to the muscles of res- 
piration. Sometimes it affects exclusively the muscles of the glottis, 
in other cases it may implicate also the diaphragm and other muscles 



278 THE PRACTICE OF MEDICINE. 

concerned in breathing. The disorder must not be confounded with 
laryngitis stridulosa, in which there is inflammation of the glottis 
with spasm superadded. Laryngismus as it affects the vocal chords 
is a pure spasm, arising, as other spasmodic attacks are so apt to do 
in the child, from reflex irritation." (Eustace Smith, " Diseases of 
Children.") 

It is more common in England than in this country. It occurs 
under two different conditions. In the new-born in whom no other 
deviation from health can be observed, and in rickety children between 
the ages of six or eight months and two years. It occurs almost 
invariably in winter, and the attacks occur night or day, when the 
child awakes. There is no cough, no hoarseness, but the respir- 
ation is arrested and the child struggles for breath, the face gets con- 
gested, and then with a sudden relaxation of spasm, the air is drawn 
into the lungs with a high-pitched, crowing sound, which has given to 
the affection the name of " child crowing." Convulsions may occur 
during the attack, or there may be carpo-pedal spasms. The fingers 
are firmly clenched upon the thumbs and the toes are flexed under the 
feet. In complicated cases the diaphragm and muscles of the chest 
are involved, and there is convulsive retraction of the abdomen. 
The heart may be affected by spasm, and act irregularly and tumult- 
uously, with small, frequent, and irregular pulse. I have seen cases 
where there seemed to be a general tonic spasm, almost a tetanus. 
Death may occur in such cases, even when apparently mild, and 
uncomplicated, from asphyxia. According to Dr. J. Solis Cohen, 
death may occur from incarceration of the epiglottis, which is drawn 
forcibly down until its free edge is caught between the posterior face 
of the larynx and the wall of the pharynx, so as to cover the glottis 
like a lid and completely occlude it. Sometimes sudden death takes 
place with all the symptoms of fatal syncope. 

In new-born babies it may be mistaken for infantile tetanus. It 
can hardly be mistaken for spasmodic croup, for there is no fever, 
hoarseness, or cough. The exciting causes are teething, undigested 
matters in the stomach, fright, anger, and bad dreams. The strug- 
gles of a child when taking medicines, whether bad tasting or not, 
will often excite a spasm. Mothers and nurses call the attack " hold- 
ing the breath." 

Treatment. — If the child is seen during the attack the inhalation 



DISEASES OF THE RESFIRATORY SYSTEM. 279 

of ammonia smelling salts will often cut it short, or in other cases a 
few drops of amyl nitrite, or chloroform, used before the epiglottis 
is closed. Dashing cold water in the face is quite effectual in short- 
ening the spasm. Thrusting the oiled finger deep into the throat, by 
provoking vomiting or disengaging the epiglottis, will arrest it. The 
radical treatment should consist in cold sponging or bathing. Place 
the child in a sitting posture in a tub of cool or warm water, then 
with a sponge wet in cold water rapidly sponge the head, neck, and 
back. This should be repeated two or three times a day. The child, 
warmly dressed, should be kept in the open air, even in cold weather, 
several hours a day. 

In selecting the remedy, not only the local spasm, but the gen- 
eral condition of the child, should be considered. If the child comes 
of neurotic parents whose other children have chorea or some such 
neurosis, aurum bromatum is a valuable remedy. Aurum is almost 
specific in epileptiform convulsions, night terrors, and the spasmodic 
stage of whooping cough. The bromide has been found useful in 
petit mal, even in grand mal. In spasm of the glottis the bromide 
is best, but chloride of gold and sodium has proven efficacious in my 
hands. To very young infants give the 6x trituration ; older chil- 
dren require the 3x ; two grains three times a day. 

Arsenite of copper is next in value. Both are indicated in a large 
proportion of cases when the children are anaemic, cachectic, or 
rickety. The 3x or 6x according to the age should be persistently 
given for weeks. A leading indication is that some spasmodic symp- 
toms persist all the time. 

Moschus is highly recommended by Eustace Smith and Lilienthal. 
It is homeopathic to recent cases in children in ordinary health, and 
when some remote irritation or a hysteric temperament is an excit- 
ing cause. A grain of the 2x every six hours. 

Gelsemium has cured many cases when the exciting cause has 
been the cutting of a tooth. The inspiration is long and croupy, the 
expiration sudden ; the child's face is scarlet, not dusky. 

Bromide of camphor, especially in female children, acts favora- 
bly. The general nervous erethism of the child, with spasms which 
threaten to end in collapse, calls for its use. Dose, lx to 3x tritur- 
ation in grain doses three times a day. 

Sambucus was recommended by Hahnemann from symptoms of 



280 THE PRACTICE OF MEDICINE. 

his own proving. I do not consider it indicated for true spasm of 
the glottis without cough, fever, or catarrhal symptoms. Sambucus 
has all of these, and the spasm is a complication. When used for 
these conditions it is invaluable. It should be useful when the 
spasm is associated with profuse bronchorrhcea. Passiflora ought 
to be a good remedy for this condition, but we have no clinical expe- 
rience in its use. Chlorine has been recommended. 



ACUTE CATARRHAL LARYNGITIS. 

Definition. — A simple inflammation of the mucous membrane of 
the larynx, often extending to the submucous tissue. Four-fifths of 
of all the mortality from this disease occur in children before the 
tenth year. In some cases the disease is complicated with rheuma- 
tism of the muscles of the larynx. It is generally caused by expos- 
ure to cold and dampness, especially if the neck is the part exposed. 
It is a common attendant of influenza and la grippe, and occurs in 
measles and other eruptive diseases. The symptoms are soreness 
and pain of the throat in the region of the larynx. In rheumatic 
cases external pressure is very painful. If hyperesthesia of the 
larynx is present, coughing excites spasm of the glottis, and any- 
thing around the throat, however loose, causes great anxiety and a 
feeling of suffocation. The cough is hoarse, barking, and generally 
occurs in severe paroxysms. The cough has a " barking " sound 
when the vocal cords are thickened and tense. The voice is cracked, 
deep, hoarse, and sometimes lost. The aphonia is caused by the 
swelling of the vocal cords, preventing vibrations. The expectora- 
tion, at first scanty, is in the early stage clear and glassy; later, 
thicker and more turbid ; and finally yellow and purulent. Dysp- 
noea is sometimes extreme if the submucous tissue is much affected. 

Treatment. — In mild cases with some fever, aconite is the only 
remedy needed. Belladonna acts well, if there is pain on swallow- 
ing, with face flushed, and a sensation of dryness and constriction 
in the throat. 

Iodide of lime is an admirable remedy when there is rawness, 
burning, soreness and tenderness of the larynx, with frequent cough, 



DISEASES OF THE RESPIRATORY SYSTEM. 281 

hoarse, and barking, and a sensation of tightness and constriction. 
Dissolve five grains of the crude drug in half a glass of water, and 
give a teaspoonful every half hour. 

Hepar sulphur is useful in nearly all cases, when there is hoarse- 
ness, deep, coarse voice, and a hollow, barking cough. 

Phosphorus when the cough is dry, or expectoration scanty, some- 
times blood-streaked, and there are painful stitches in the larynx ; 
speaking or change from warm to cool air aggravates. 

Spongia when the cough is shrill, crowing, and dry; or with 
fine wheezing in the larynx, with scanty, tenacious expectoration. 

Sanguinaria when the cough is constant, painful, hoarse, or bark- 
ing. It often relieves when hepar sulphur and spongia fail. Inhala- 
tion of hot lime water; swathing the throat with cool or warm 
water compresses ; or the rubbing in of lard or vaseline, gives 
decided relief. If spasmodic or suffocative paroxysms occur, give 
hyoscyamus or sambucus. The former when the cough is very dry ; 
the latter when there is excess of mucus. 

(Edema of the larynx extending to the glottis, epiglottis, and 
arytenoids, generally occurs during attacks of laryngitis. It may 
attend scarlet fever, measles or typhoid fever. It is a swelling 
marked by rapid infiltration and serous effusion. 

The chief remedy is apis mellifica (or preferably apium virus, a 
trituration of the stings alone). Many years ago I cured with 
lachesis lOx two of the few cases I ever treated. The enlarged 
epiglottis was livid in spots and the slightest touch to the external 
throat caused terrible suffocative spasm. The pellets were placed 
on the tongue and gave relief in a few hours. 

Iodide of potassium will cause acute oedema of the larynx and 
glottis, even in small doses, in some persons. A case was recently 
reported in which calomel was given, alternately with the iodide of 
potassium, which resulted in almost fatal oedema of the larynx. The 
reporter supposed iodide of mercury was formed. But the iodide 
of potassium should have been given alone. It ought to act cura- 
tively in oedema in very small doses. 

Arsenic is said by J. S. Mitchell to be " the remedy par excel- 
lence for this affection." It may be, but not for acute cases. It is 
better when there is a low state of the blood, which would induce 



282 THE PRACTICE OF MEDICINE. 

oedema anywhere. Iodide of arsenic would have a more prompt 
effect. 

Some lives have been saved by deep scarifications. Application 
of a three per cent cocaine solution has been recommended, but I 
doubt its value. 

Dr. Mendoza (" Journal of Laryngology ") injected one-third of 
a grain of pilocarpine, divided into three doses, which were given at 
twenty-minute intervals, with the result that calm, good breathing 
took the place of the severe dyspnoea from which the patient suffered 
previous to the injection. 

In one case where oedema threatened, I obtained relief after 
giving five doses of one-hundredth grain of the muriate of pilocarpine 
on the tongue, repeated every fifteen minutes. 

CHRONIC LARYNGITIS. 

This disease sometimes follows an acute attack, but oftener arises 
from an extension of a pharingitis. It may be simple, tubercular, 
or syphilitic. 

The most common symptoms are a hacking short cough, or a 
" hemming," induced by a desire to clear the throat. The pains 
are tickling, burning, sticking, and stinging, with a sensation of ful- 
ness and tension. 

There are alternations of the voice, from hoarseness to complete 
aphonia. The hoarseness is worse on rising in the morning, or after 
sunset. It improves after eating, and using the voice in the morn- 
ing, but is aggravated by talking or singing in the evening. All the 
symptoms are worse in cool and damp weather, and they improve 
in warm dry weather, and in the climates of Florida, Cuba, and a 
few warm protected valleys in Southern California and New Mexico. 

Treatment, — Iodine, iodide of lime, hepar sulphur, spongia, phos- 
phorus, and sanguinaria, used in the acute stage, are equally valu- 
able in the chronic. In addition, aurum, argentum, cedron, collin- 
sonia, bromine, carbo vegetabilis, causticum, eriodictyon, bichromate 
of potassium, creosote, naja, phytolacca, iodide of potassium, nitric 
acid, rumex, nitrate of sanguinaria, stillingia, senega, silphium, and 
wyethia, are all useful remedies. 



DISEASES OF THE RESPIRATORY SYSTEM. 283 

Aurum, iodide of potassium, phytolacca, and stillingia are the 
remedies when the affection is syphilitic. The dose is of great 
importance. Aurum will cure in the 3x or 6x. Iodide of potassium 
must be given in large doses, not less than one to ten grains three 
times a day. Kicord cured intractable cases with enormous doses, 
half an ounce a day, but its action in such doses must be watched, as 
in some persons it causes sudden oedema of the glottis with danger- 
ous results. 

Phytolacca and stillingia are useful in doses of ten to sixty drops 
three or four times a day. 

I have had the best success in non-specific cases with hepar sul- 
phur, causticum, phosphorus, eriodyction (yerba-santa), creosote, 
nitrate of sanguinaria, and silphium. In follicular laryngitis, I pre- 
fer iodide of mercury, sabal, seleniate of soda, and iodine internally ; 
and topically by means of an atomizer throwing a very fine spray, or 
a steam atomizer throwing a vapor. I have seen the happiest results 
follow the use of a vapor of copaiva, creosote, sabal, iodine, cubebs, 
eucalyptus, and thuja ; five per cent solutions in albolene. Resor- 
cin has proved of great value in some cases. 

When there is a suspicion of tuberculosis, creosote is the most 
important remedy, and in material doses. Begin with one-tenth of 
a drop in syrup of Balsam Peru, and increase this gradually to one 
or even five drops. When more than one drop is given, the best 
method is in capsules, which are now prepared ready for use. An 
emulsion of cod-liver oil with one grain of hypophosphite of lime 
and one drop of creosote to each dessert spoonful has enabled me to 
cure several cases where emaciation and hectic were present. 

Hygienic Rules. — Never allow patients to swathe the throat 
in flannels, but insist that they go with the neck exposed day and 
night, bathing it in cold water, with a brisk rubbing afterwards. 
Advise men to wear not a full beard, but rather a mustache. The 
best climate is either cold and dry, or warm and moist. Send patients 
to either during the winter and spring and they will improve. 
Probably the best climate in the United States is in the interior of 
Florida, between latitudes 23° and 27°, on high rolling pine lands. 

Sulphur waters moderately used generally benefit sufferers with 
chronic laryngitis. White sulphur springs are the best. 

I have treated many great vocalists, prima donnas, and tenors, 



284 THE PRACTICE OF MEDICINE. 

and it may be of some interest to know what medicines benefited 
them most. 

Christine Nilson always received immediate benefit from phos- 
phorus 2x. On several occasions it restored her voice in a few hours. 

Clara Louise Kellogg was always relieved of hoarseness, rawness, 
and desire to clear the throat, by copaiva and proto iodide of mer- 
cury. The late Dr. John F. Gray of New York prescribed copaiva 
for her, always in the lx trituration. He considered it one of our 
most valuable remedies for catarrhal hoarseness. 

Mme. Lucca was benefited only by iodide of potassium, two grains 
three times a day. On one occasion causticum 3x gave her unex- 
pected power to sing. She habitually drank while singing a bever- 
age composed of equal parts of claret and black tea. 

Gottschalk's favorite medicines were phosphorus and hepar sul- 
phur. 

When vocalists feel as if they had exhausted the tonicity of the 
vocal cords, and it is with difficulty that they keep up the requisite 
respiratory efforts, a teaspoonf ul of the tincture of coca, or a wine- 
glass of wine of coca, restores temporarily the weakness of voice 
and respiration. But Professor See, of Paris, says this use of the 
drug must not become a habit, as it eventually weakens the larynx, 
and renders it very sensitive. 



MEMBRANEOUS LARYNGITIS. 

Definition. — An inflammation of the larynx with membraneous 
exudation. The best authorities now recognize two forms of this 
disease : (1) A simple, non-specific, non-contagious affection, local 
in its nature and not occurring in epidemics. (2) An effect of 
diphtheria, in which the disease may be limited to the larynx, but 
most commonly is associated with exudation on the pharynx or 
tonsils. 

Etiology. — Many authorities regard membraneous croup as always 
diphtheritic. I see no more reason for this opinion than that every 
case of membraneous mucous enteritis is diphtheritic. In my early 
practice I treated several cases of membraneous croup occurring in 
farm-houses remote from any other residence. They recovered after 
expelling casts of the larynx, without having a single symptom of 



DISEASES OF THE RESPIRATORY SYSTEM. 285 

diphtheria, and with no sore throat, or exudation, either on the 
pharynx or tonsils. 

Osier (" Practice of Medicine "), the highest and latest author- 
ity on pathology, says : " Provisionally at any rate, I still hold that 
there is a separate independent affection, a non-contagious mem- 
braneous croup." 

Mitchell (Arndt's " System of Medicine "), an equally high 
authority in our school, says : " We do maintain from the weight of 
evidence, and from the combination of all the clinical and anatom- 
ical facts, that it is possible to establish an absolute dissimilarity as 
between croup and diphtheria." 

Symptoms. — The symptoms relating to the larynx are quite sim- 
ilar in non-specific and specific cases. Both begin like an acute 
catarrhal laryngitis. The child has a cough, croupy in character, 
with some hoarseness, for several days, when, usually at night, the 
patient suddenly becomes worse, and there are signs of impeded res- 
piration. At first the difficulty of breathing is paroxysmal, due 
probably to more or less spasm of the glottis ; soon the dyspnoea 
becomes continuous, inspiration and particularly expiration are dif- 
ficult, and with the inspiratory movements the epigastrium and lower 
intercostal spaces are retracted. The voice is husky and may be 
reduced to a whisper. The color gradually changes, and the imper- 
fect aeration of blood is shown in the lividity of the lips and finger 
tips. At times during the dyspnoea the child has suffocative attacks, 
shows great anxiety and distress, will not lie covered, wants to be 
carried all the time, begs to be put back in bed, but soon wants to 
be taken up again. The cyanosis is observable on the mucous sur- 
faces, showing the carbonic acid poisoning to be universal. The 
dyspnoea and the stridulus breathing are most distressing to the 
parents and physician. The dyspnoea is due to a spasm of the glot- 
tis. That may extend to the terminal nerve filaments of the bron- 
chioles, and add greatly to the apnoea. 

The breathing has a sibilant, tubular, and metallic quality, with 
a very high pitch. There is a prolonged inspiration, with a wheez- 
ing, whistling, sneezing sound, sometimes heard for a long distance. 
The expiration is marked, and accompanied by a rattling of mucus, 
and is distinguished from the sharper and sawing quality of the 
inspiration sound by its lower tone. 



286 THE PRACTICE OF MEDICINE. 

The temperature may reach as high as 103°, but is commonly 
about 100°. If it goes up to 104° or 105°, bronchitis or pneumonia 
is present. The pulse is full, hard, 120 to 130, but during the suf- 
focative attacks may rise twenty or thirty beats ; the respiration is 
thirty to forty or more per minute. There is a difference of opinion 
as to the cause of the dyspnoea. Probably no one cause, but several, 
both mechanical and neurotic, explain it. There may be great dysp- 
noea with but a small quantity of membrane, and vice versa, show- 
ing that spasm of the glottis and bronchioles play a large part in 
causing the difficulty of breathing. The exudate or false membrane 
is not very closely attached to the mucous membrane. Piece by 
piece it may nearly all become detached and a decided remission 
occur. The fever will abate, the cough become loose, the dyspnoea 
nearly disappear, and the sleep and appetite return. But these 
remissions are often delusions. The membrane has a tendency to 
return, and then all the dreaded symptoms will come back. Chil- 
dren rarely if ever survive a relapse, for the first attack has left 
them so weak they cannot rally sufficiently to overcome a second. 

The exudate when thrown off varies from a very thin pellicle to 
a thick, firm, tenacious, false membrane, which may entirely block 
up the larynx. Cases are on record in which a cast of the larynx 
with a central hole the size of a pipestem only was expelled, fol- 
lowed by recovery. The color is yellowish white, brown, or gray ; 
it may be almost black from extravasation of blood, streaked and 
dotted with minute clots. 

The full duration of membraneous croup is four or five days, but 
it may terminate in forty-eight hours. The non-diphtheritic may 
last longer, because of the absence of the diphtheritic poison in the 
blood. There can be no absolute diagnosis, except by examining 
the membrane. If the bacillus of Loeffler is found, that settles the 
matter. 

Whether diphtheritic or not, few cases of membraneous croup 
recover if tracheotomy is not resorted to. The literature of both 
schools has many alleged cures, not all trustworthy unless the mem- 
brane has been seen after the expulsion. Pieces of dry mucus or 
shreds of tenacious mucus are often supposed to be membraneous. 
The mortality is from sixty to eighty per cent (Osier) ; eighty per 
cent is nearer the truth. When it attacks robust children and is 



DISEASES OF THE RESPIRATORY SYSTEM. 287 

not diphtheritic the chances are better. A very small exudation may 
prove fatal. Death is almost inevitable when the exudate extends 
to the bronchi. 

Treatment. — The treatment of the two kinds of membraneous 
croup is essentially the same, even if we could make an accurate 
diagnosis, for we have no known antidote to the poison of diphtheria. 
Have we one or more medicines which, taken internally, not inhaled, 
can cause in a healthy child all the phenomena of this disease? 
The causation of a false membrane in the larynx by the inhalation 
of a caustic drug does not make it homeopathic to the disease. I 
believe the exudate is the external manifestation of the poisonous 
action of some toxic principle in the blood, and not the local poi- 
sonous action of the bacilli. Even in non-diphtheritic cases the mem- 
brane does not resemble the local action of drugs such as caustic 
ammonia, sulphuric acid, or nitrate of silver. It has been claimed 
for bromine, bryonia, cubebs, hepar sulphur, bichromate of potas- 
sium, iodine, and spongia, that they cause an exudate in the larynx 
closely resembling that of croup, but no post-mortem evidence' has 
been presented in proof except those observed in animals. 

Bromine has been supposed to be the nearest similimum for 
membraneous croup because it causes a similar exudate in the larynx 
of pigeons, and similar subjective symptoms in men. There have been 
a few cases reported which recovered under its administration. I 
am sorry to say that in the numerous cases of diphtheritic croup in 
which I have prescribed it, or observed its use in the hands of my 
colleagues, I cannot recall a single cure. I can say, however, that 
when the diphtheritic exudate appeared only on the pharynx and 
fauces, I think I have seen it disappear under its use. If used in 
true laryngeal croup, it should be given in watery solution, 1 to 
1000, a teaspoonful every hour ; and the air of the room should be 
faintly impregnated with its fumes, not strong enough to cause any 
irritation when it is breathed. 

It was supposed that the experiments of Dr. Currie of Paris, in 
which he caused false membranes on the laryngeal and bronchial 
mucous membrane of rabbits by the internal administration of bry- 
onia, would lead to some favorable results. Clinical experience, how- 
ever, has dissipated any such hopes, as not a single case of mem- 
braneous croup has been reported cured by bryonia. Teste's asser- 



288 THE PRACTICE OF MEDICINE. 

tion, like all his other bold statements, that ipecac and bryonia will 
cure all cases of croup, is now considered not worthy of considera- 
tion. Ipecac will palliate the dyspnoea, but has no other influence 
except that it may render the membrane less tough, by causing it to 
contain more water. This it may do when given in doses sufficient 
to get its physiological action as an expectorant. 

Iodine is more capable of causing true croupous exudation than 
bromine or any other drug except bichromate of potassium. Both 
are said to have caused membraneous laryngitis when taken intern- 
ally. Iodine has been credited with a larger number of cures of this 
disease than any other drug, and should be used as I have advised 
in the case of bromine. Many of our school assert their confidence 
in iodine in all species of croup, and consider it the best plan to 
give it in all cases of laryngitis, whether catarrhal, follicular, or 
membraneous. 

Bichromate of potassium is also given the credit of curing many 
cases. Its action is more intense than that of iodine, consequently 
we may expect the exudation to be thicker, more bloody, and to 
extend into the sub-mucous tissues. A study of its symptoms and 
pathology will show a striking resemblance to ulcerative diphtheria 
with tough, tenacious membranes. The 3x or 6x trituration is gen- 
erally prescribed, but I know of some homeopathic physicians, once 
members of the dominant school, who give the lx trituration until 
it causes vomiting, and assert that it not only expels the membrane, 
but has a better curative action in such doses. But what shall we 
say to the assertion of Lippe, Swan, Berridge, and others of the 
ultra Hahnemannian wing of our school, who claim to cure croup 
with the 200th or m.m. of this same drug ? Shall we believe them 
in this, and not believe them when they assert that they cure diph- 
theria and membraneous croup with the highest potencies of lac 
caninum? 

Cubebs is rarely mentioned in our books as a remedy for mem- 
braneous croup. Yet it is well known that its long continued use 
in large doses has caused so severe a catarrhal laryngitis, with such 
excessive quantity of tough stringy mucus, as almost to lead to suf- 
focation. Some of the expectorated matters seemed like false mem- 
brane. Discredit was thrown on this statement because it appeared 
in Houatt's pretended provings, but he probably copied it from some 



DISEASES OF THE RESPIRATORY SYSTEM. 289 

author who was the real authority. Several years ago, I found in some 
medical journal of the regular school a report of several cases cured 
by cubebs in large doses. "While I have never used it in diphther- 
itic croup I have found the oleo-resin of decided value in catarrhal 
pharyngo-laryngeal catarrh, both in adults and children, when the 
expectoration was stringy, almost membraneous, and very diffi- 
cult to detach. It seems capable of causing a catarrh like bichro- 
mate of potassium, without its lesions of mucous surfaces. I would 
suggest its use in the form of a vapor, made with cubeb water, pre- 
pared in the same manner as eucalyptol water, and also the internal 
administration of five grain doses of the lx trituration of the pow- 
dered cubebs. Lilienthal evidently considered it worthy of mention, 
for he gives full indication for it in his " Therapeutics." 

The above are all the medicines supposed to be homeopathic to 
true membraneous croup. But we should not content ourselves with 
their use alone. There are other medicines which may palliate and 
aid the action of the specifics. If the temperature in the beginning 
or at any time, is high (103°) with a small hard pulse, great rest- 
lessness and anxiety, aconite is useful. Gelsemium, if there seems 
to be spasm of the glottis, with scarlet red face and a stupor. 

There are several medicines that palliate the excessive dyspnoea 
when not altogether due to the amount of exudation. Ipecac is use- 
ful, and has given much relief. Sambucus, bromide of potassium, 
bromide of gold, lachesis, aspidospermin, naja, and lobelia. This 
last drug was considered by the early Botanic and Eclectic schools 
as the sheet anchor in membraneous and other croups. In small 
doses it relieves the spasmodic dyspnoea as I have found in my own 
experience. They used it in emetic doses, and claimed that it not 
only made the breathing easy and free, but expelled the membranes 
as fast as they formed. I have no doubt that some cases were cured 
by its heroic use, when the child was supported by nourishing food 
and stimulants. In all dyspnoeas even when of mechanical origin, 
quebracho has wonderful palliative power. It does this through its 
action on the nerve centres in the medulla ; as the crude drug is 
offensive, and given with difficulty to the children, I have used the 
first centesimal trituration of its alkaloid, aspidospermin, in two to 
five grain doses every hour, with gratifying results. 

Jaborandi, as is well known, causes an extremely thin, watery 

19 



290 THE PRACTICE OF MEDICINE. 

condition of the saliva and other secretions of the mouth and throat. 
Given in catarrhal conditions, it soon renders the discharge freer 
and thinner. Several physicians have used it in croup with alleged 
good results, Dr. Doom (in " Therapeutic Gazette") writes, " I 
think I have discovered in the jaborandi, a sovereign remedy, if not 
a specific, in pseudo-membraneous croup. Five drops every half 
hour is just enough to keep up a free flow of saliva, and moisten the 
surface, thus inducing an exudation (watery) between the membrane 
and the trachea, preventing its formation, and loosening that already 
formed." Others write as enthusiastically, but the drug is depress- 
ing and should be used with caution. It can be given in non-de- 
pressing doses, yet enough to cause a free flow of watery mucus. I 
recommend the alkaloid, pilocarpin, in doses of one-tenth or one- 
twentieth of a grain, as it will have a better effect than the crude 
jaborandi. If the mouth and the throat of the patient were dry, I 
certainly should use it in such doses. If, on the contrary, the secre- 
tions were in excess and very thin, the 6x would be homeopathic. 
It is reported to have saved life in pulmonary oedema when given 
in physiological doses. 

The late Dr. Thomas Nichols of Montreal, author of a most 
admirable treatise " On the Respiratory Diseases of Children," 
accords to sanguinaria the highest place in the treatment of mem- 
braneous croup. He had an opportunity of testing its value in a 
large number of cases one winter, and his reports were published in 
our Journals and in my " Therapeutics of New Remedies." He 
first used the sanguinarin, the mixed active principles of the root, 
one grain to four ounces of water, and with this he cured several 
cases. Then acting on the suggestion of Paine, an eclectic, he used 
the acetous tincture of the root, — made by dissolving twenty grains 
of sanguinaria, (pulverized root) in four ounces of vinegar and one 
ounce of syrup, the dose being a teaspoonful. This preparation 
became very popular with him, and he regarded it the best in use. 
(Lilienthal recommends acetic acid in membraneous croup.) He 
reported many cases of undoubted membraneous laryngitis, where 
the membrane could be seen on the epiglottis and pharynx, cured by 
this remedy alone. He recommends an acetous tincture with four 
grains of the root to two ounces of vinegar and one ounce of syrup, 
which he considers strong enough. Lately, eclectics are using the 



DISEASES OF THE RESPIRATORY SYSTEM. 291 

nitrate of sanguinarin, and assert that it is superior to any other 
preparation. It is a powerful drug, possessing caustic properties, 
and acting as a violent emetic in fractional gram doses. It has been 
proved by Dr. William Owen of Cincinnati, and the symptoms of 
the pharynx and larynx were such as to leave no doubt that it is 
capable of causing membraneous laryngitis. This drug should be 
used in trituration or dilution, from the 3x to 6x, according to the 
age of the child, and continued until the symptoms abate. 

The topical treatment of this disease has been nearly that of 
diphtheria. At one time, and even at the present, the vapor of 
slacking lime was used. The unslacked lime was placed in a jar or 
tea kettle, and water poured upon it. The patient was made to 
inhale the steam or vapor arising from it. My brother, the late Dr. 
P. H. Hale, cured several cases by this method, under my observa- 
tion. Lime water (" aqua calcis ") has been used in the same way 
and with good results. The vapor of lime acts by softening and dis- 
integrating the false membrane, allowing its easy detachment. A 
vapor of soda, potash, or ammonia has been used in some cases 
with apparent benefit. 

The digestive products have been tried with varying results. 
Good effects have been claimed for pepsin, trypsin, papayotin, 
Merck's juice of the paw paw, or Johnson's papoid (see Diphtheria). 
They act by digesting the membrane, causing it to disintegrate and 
loosen its hold on the mucous surfaces. 

The vapors of iodine, bromine, bichromate of potassium, nitrate 
of sanguinaria, cubebs, and other drugs homeopathic to the patho- 
logical condition, have been used, and cures are alleged to have been 
made by them, but the same drugs have been at the same time given 
internally. Probably their topical, aided their internal use. 

The nourishment of the child should not be forgotten. So long 
as the child can swallow, milk, and milk gruels, beef essence, mut- 
ton broth, and wine whey should be given. If the dyspnoea is some- 
times so great and the restlessness so extreme that the patient can- 
not be fed by the mouth, then rectal feeding must be resorted to. 
Injections of beef tea or milk beaten up with eggs and essence of 
pepsin or pancreatin, should be thrown up into the colon, or enough 
to fill the rectum. Mosquera's beef meal is predigested and makes 
an excellent enema. It should be made as strong as can be injected. 



292 THE PRACTICE OF MEDICINE. 

Old brandy, whisky, or Hungarian tokay beaten with eggs, can 
sometimes be given by the mouth when no other food can. Do not 
delay tracheotomy or intubation too long ; when cyanosis appears, 
be ready for one of the operations, for they have saved many lives. 



BRONCHIAL OR SPASMODIC ASTHMA. 

Definition. — The name asthma should be applied only to certain 
conditions of the bronchi which cause intense dyspnoea. The dysp- 
noea caused by renal, cardiac, and other diseases should be 
assigned to its special cause. There are several theories of the 
nature of asthma. 

(1) That it is a neurosis, causing spasm of the bronchial mus- 
cles ; or (2) turgesence of the mucosa which may be a functional 
hypersemia, a vaso-motor turgesence, or diffuse hypersemic swelling. 

There are many reasons to suspect that it is due to the same con- 
dition of the system that causes hay fever. Hay asthma differs very 
little from any other asthma. The idea that hay fever invariably 
comes on in the summer is a mistake. I have had it many times 
during the winter months, and have known it to occur in others at 
any time during the year. The same condition is present in the 
bronchial that is present in the nasal passages ; the same exudation 
of mucus, at first thin and irritating, then thick and glairy, and dif- 
ficult of expulsion on that account. Dyspnoea is the " sneezing " of 
the bronchi, an affection in which the bronchi and the diaphragm 
are in a state of spasm. 

Osier (" Practice of Medicine ") points out many other resem- 
blances, among which are causes of asthma identical with those of 
hay fever. It runs in families with irritable nervous systems. Men 
are more affected than women. A person may be free from it in 
the city and suffer invariably from it in the country, and vice versa. 
He may have attacks of it all the year in the first floor of his house 
and yet get rid of it by removing to the third floor. I have known a 
change of residence from one street to another not far away, to arrest 
it. Some persons have it on land, but never on board ship, or on 
an island. Breathing the air of a dusty or musty room, odors of 
flowers, hay, manure, the emanation from any animal, as the horse, 



DISEASES OF THE RESPIRATORY SYSTEM. 293 

dog, cats, rats, and mice, and particularly the skunk (mephitis) will 
bring on a violent attack. Fright, anger, and other emotions may- 
precipitate it. 

In chronic cases, when complicated with emphysema, every 
"cold " brings on an attack, also every attack of indigestion, or over- 
eating. It is often associated with polypi in the nose, or hyper- 
trophic rhinitis. 

Salter mentions some cases which seem to alternate with epileptic 
attacks, both diseases arising from the same neurotic element. The 
division into dry and humid asthma is obsolete. In the first stage 
of an attack it is always dry, and moist only after the second stage 
has set in. The line of demarcation between bronchitis and asthma 
is quite uncertain. In some persons an attack of bronchitis always 
ends in asthma. 

Generally, a paroxysm of asthma is preceded by a coryza, or dry 
bronchial cough. Then, often in the night, after a few hours' sleep, 
the patient is aroused with a distressing sense of want of breath, and 
a feeling of great oppression of the chest. Soon the respiratory 
efforts become violent, all the accessory muscles are brought into 
play, and in a few minutes the patient is in a paroxysm of most 
intense dyspnoea. The face is pale, expression anxious, speech is 
impossible, and in spite of the most strenuous efforts, very little air 
enters the lungs. 

Expiration is prolonged and wheezy, the number of respirations 
is not much increased. The fit may last a few minutes or several 
hours. 

In severe paroxysms signs of defective aeration soon appear, the 
face becomes cold and clammy, the pulse small and quick, the 
extremities cold, and just as the patient seems to be at his worst, 
the breathing begins to get easier, and after a paroxysm of cough- 
ing, he drops asleep, sometimes to wake with another paroxysm in a 
few hours. The cough is at first dry, and the expectoration scanty 
and expelled with the greatest difficulty. In a child it is difficult to 
diagnose this from laryngismus stridulus. In fact I believe they 
are essentially the same except as to the location. After many 
days of these paroxysms, the expectoration becomes very profuse 
with rattling of abundant mucus all through the bronchi. This was 
once called "humid" asthma. 



294 THE PRACTICE OF MEDICINE. 

Dr. CurschmaD, who discovered the condition, describes the spu- 
tum in bronchial asthma as distinctive, unlike that which occurs in 
any other affection. "At first it is brought up in the form of 
rounded gelatinous masses, the perles of Laennec. Though ball-like, 
they can be unfolded, and really represent moulds in the mucus of 
the smaller tubes. Microscopically many of these smaller pellets 
have a spiral structure. Under the microscope these spirals are of 
two forms. In one there is a simply twisted, spirally arranged mucin, 
in which are entangled cells in all stages of fatty degeneration. The 
twist may be loose or tight. The second form is much more peculiar. 
In the centre of a tightly coiled skein of mucin-fibrils, with a few scat- 
tered cells, is a filament of extraordinary clearness and translucency, 
probably composed of transformed mucin. These spirals are probably 
formed in the finer bronchioles and are the product of acute bronchi- 
olitis. After two or three days the sputum changes entirely in char- 
acter : it becomes muco-purulent and the spirals are no longer found." 

In all cases of true bronchial asthma Curschman says these spirals 
are found. Emphysema almost invariably appears in chronic asthma, 
and then while the paroxysms diminish in frequency the shortness of 
breath becomes aggravated. 

Treatment. — When called to see a patient in a severe fit of 
asthma, especially if it is the first one, the thing to do immedi- 
ately is to quiet his fears of death and the alarm of his family. 
Death never occurs in a paroxysm of true asthma. It is only in 
cardiac or renal asthma that such a result is possible. All but one 
attendant should leave the room. The best ventilation must be 
obtained without draughts blowing on the patient. A draught from 
a window open only an inch from the bottom, or from a partially 
open door, is more dangerous than to have all the doors and windows 
open. In very cold weather pull the upper sash down a few inches, 
or push up the lower sash, insert a strip of board underneath, and 
shut the sash down on it. This leaves a space between the two sashes 
through which plenty of fresh air is driven upward, and diffused grad- 
ually through the room. If the weather is above 60°, the patient had 
better sit out of doors until the attack is over. It is almost impossible 
to 'catch cold " during the paroxysm, but the moment it subsides, 
the patient is left with a relaxed perspiring skin, and is very sus- 
ceptible to the influence of a low temperature. 



DISEASES OF THE RESPIRATORY SYSTEM. 295 

The posture assumed by the patient is of great importance so far 
as his comfort is concerned. Asthmatics soon learn that the easiest 
position is sitting in a chair leaning forward upon the drawn knees. 
A few are obliged to stand holding something by the hands. The 
clothing should be loose about the neck and chest. If the attack 
comes on after eating to excess, give an emetic of warm mustard 
water ; or a dose of apomorphia by the mouth or hypodermatically. 
Give one-tenth of a grain if there is not much accumulation of mucus 
in the bronchi. As the drug causes an excess of mucus, it might not 
be safe to give it when there is much secretion. Lobelia is a pow- 
erful emetic, and is suitable if we are obliged to give a strong one, 
because it possesses some especial influence over spasmodic asthma. 
It should not be given if the patient has a weak heart or is other- 
wise delicate. Notwithstanding its great depressing influence, which 
leads old-school authorities to warn us against it, the drug does not 
seem to be so very dangerous in practice. If it had been, the early 
** botanic" physicians would have numbered their victims by the 
thousands. In the early part of this century patients were dosed 
with lobelia sometimes daily for weeks, often to the point of extreme 
vomiting, and yet the deaths must have been very few or the " steam 
doctors," as they were called, would have been prosecuted for mur- 
der, so bitter was the feeling against them. I have known asthmat- 
ics resort to it on the first appearance of the paroxysm, and take tea- 
spoonful doses of the tincture until profuse vomiting set in. After 
a short period of prostration (like that caused by acute tobacco pois- 
oning) all the dyspnoea disappears and the patient quietly sleeps. 
The hot infusion of the seeds was the favorite method of adminis- 
tration. Ten to twenty grains of the powdered leaves or seeds were 
infused in a cup of water and the whole taken at once. It causes 
prompt and thorough vomiting. I know of no drug that will cut 
short a fit of asthma unless it be lobelia. Probably an infusion of 
tobacco seeds or leaves would have about the same effect, but the 
tobacco would be the more depressing and dangerous of the two. 
I write as I do, not because I am in favor of the drug, or use it, for 
I never prescribe it as an emetic in an asthmatic paroxysm, but I 
think old-school writers are unduly prejudiced against it and have 
exaggerated its dangers. If it is not necessary to evacuate the 
stomach, lobelia in ten-drops doses every half hour will certainly 



296 THE PRACTICE OF MEDICINE. 

shorten the duration of the paroxysm. I use the following formula : 

1^ Tine, lobelia drm. i. 

Chloroform water oz. i. 

Give a teaspoonful every half hour or oftener until relieved. 

There are some remedies that act quicker than lobelia. Nitrite 
of amyl will lessen the severity of the fit in a minute or less. If the 
hands and face are cold and bathed in cold sweat, the heart's action 
feeble, and the spasmodic constriction of the bronchi severe, a few 
whiffs of amyl will relieve in an incredibly short time. If the 
depression is not severe, inhaling a few drops of chloroform will 
have a prompt, favorable effect. 

Glonoine or nitrite of soda is better when we desire to get more 
lasting results. Dr. Pierce ("Practitioner," March, 1891) gives 
of the latter three or four grains, repeated every hour or two. In 
some cases I have injected under the skin one-fourth of a grain of 
morphine with one-hundredth of a grain of atropine. 

Osier advises cocaine instead of atropine, and says it has proved 
very satisfactory in obstinate recurrent cases (one-eighth of a grain 
of morphine with one-fourth of a grain of cocaine). A common 
remedy, and one that generally gives prompt relief, is the fumes of 
nitre. Soft, bibulous brown paper is soaked in a saturated solution 
of nitre (saltpetre); this dry paper, while burning, gives off fumes 
that soon relieve the oppression of the chest and the laborious 
breathing. If a decoction or tincture of stramonium is mixed with 
the nitre, it renders the fumes more antispasmodic. Cigarettes 
made of this medicated paper and smoked prove quite as effective, 
and are preferred by many patients. 

Some of the severest paroxysms I ever treated were quickly 
relieved by ten to twenty grains of hydrate of chloral ; if the heart 
is weak, chloralimid is safer, as it does not depress the circulation. 
Opium will relieve a paroxysm very quickly in some persons, but it 
should be used only in an emergency ; the best form is " paragoric " 
(tinct. opii. camph.). In the early pharmacopoeias this was known 
as " elixir asthmaticum," and when first introduced was used almost 
altogether for asthma. In the asthma of women and children it is 
as good a palliative as we can use. 

A prominent writer in " Arndt's Practice " says, " Attacks usu- 
ally yield readily to the indicated remedy." If he means that we 



DISEASES OF THE RESPIRATORY SYSTEM. 297 

can surely and quickly cut short an attack of asthma with attenuated 
medicines his experience is not like my own. I have never observed 
that our attenuations arrested or greatly relieved a paroxysm. We 
should carefully distinguish between a spontaneous subsidence of a 
paroxysm of asthma, and an arrest of it by medicines. We get a 
great deal more credit in such cases than we deserve. A paroxysm 
will last but a few hours anyhow. If we administer a medicine and 
have to continue it for several hours before decided relief comes, the 
drug has had no curative influence. If we are called towards morn- 
ing to a patient who has been suffering in a paroxysm since mid- 
night, our prescription may be followed in a very short time by com- 
plete relief ; but the subsidence of the attack was spontaneous, and 
would have occurred without the use of medicine, just as a paroxysm 
of croup subsides suddenly, after lasting an hour in the night. 

We cannot claim to have made a cure of asthma until we have 
prevented its occurrence for months and years, and that is a very 
difficult thing to accomplish. There are very few medicines capable 
of this result. 

Arsenic is the drug most likely to effect a real cure of asthma. 
I need not enumerate the symptoms which indicate it, for it has in 
its pathogenesis nearly all the typical symptoms of asthma. It is 
the only drug I can conceive of, capable of causing a bronchiolitis, 
which is supposed to be the essential lesion in true asthma. It cor- 
responds to the nocturnal periodicity and the neurotic nature of the 
malady. In all the cases of chronic arsenical poisoning we see the 
asthmatic and bronchial symptoms stand prominently forward. An 
apparent contravention of this statement is the familiar story of 
the arsenic eaters of Styria, who gain great powers of endurance in 
mountain climbing, and labor in high altitudes. Its use there is 
traditional, just as is the use of coca by the mountaineers of Peru, 
and when taken to relieve the breathing rendered difficult by the 
rarified air, the system becomes capable of tolerating its use in large 
doses. But the arsenic eater cannot stop its use ; he has to con- 
tinue it until he dies. If he does not he suffers from all the symp- 
toms of arsenical poisoning. Women who grow plump, and get a 
pearly skin from its use, grow thin, scrawny, sallow, and in every 
way unlovely when they cease to use it. 

Arsenic cures asthma not so much by its local specific action as 



298 THE PRACTICE OF MEDICINE. 

by its general effect on the nutritive and reparative functions. It 
may be called a tonic to the nervous and digestive systems. It cures 
asthma as it cures chorea, neuralgia, degeneration of the mucosa of 
the stomach and bowels, by the profound influence it exerts on the 
nervous tissues. It is of no value in the paroxysm itself, but must 
be used continuously for weeks and months, or until the asthmatic 
tendency is removed. I have had the best results from its use when, 
beginning with one drop of the lx of Fowler's solution after meals, 
the dose was increased by one drop at each time until thirty drops 
were reached ; then decrease in the same ratio until the first named 
dose is reached. Then suspend its use for a week and go on again. 
In this way a radical cure may be attained. Other appropriate med- 
icines may be used for the recurring attacks or complications, with- 
out interfering with the action of arsenic. 

The only other remedy which can compare with arsenic is iodide 
of potassium, and it is probably the iodine which is the curative 
agent. The chief diagnostic difference between arsenic and iodine 
in asthma is, that arsenic is more useful in asthma with dry bron- 
chitis, while iodine acts better when mucous rales are present, or in 
«' humid " asthma. The best method of giving iodide of potassium 
is to begin with one grain (one drop of a saturated solution), and 
increase by one drop until ten drops (grains) have been reached, 
then decrease the dose in the same ratio. It acts best when taken 
in Vichy water, milk, or any alkaline water ; and should be given 
three hours after meals. Dr. Salter, the highest authority on 
asthma, says it will cure about one case in five of chronic asthma. 
He says it has to be continued for a week or two before any bene- 
ficial results are seen. He reports several typical cases cured by 
this drug when all other medicines that had been tried for many 
years had failed. 

It may be beneficial in some cases, for meeting certain symptoms, 
to use the arseniates and iodides. The arseniate of gold for children, 
when asthma is accompanied with laryngismus stridulus (3x trit.). 
Arsenite of antimony 2x when there is pulmonary congestion and a 
weak heart, together with prominent antimonial symptom. Arsen- 
iate of strychnine 2x when the muscular tone is very low, particularly 
when the respiratory muscles are weak (one tablet four times a day 
for a week) . Arsenite of copper when the cuprum symptoms are pre- 



DISEASES OF THE RESPIRATORY SYSTEM. 299 

dominant. Arseniate of iron in anaemic girls, who have attacks of 
dyspnoea on slight exertion. 

Ipecac, tartar emetic, and tobacco are praised only as palliatives 
by Dr. Salter, and he asserts that no relief ever comes from these 
drugs until nausea sets in. This is my experience, and I believe all 
close observers will agree with me. Notwithstanding the professed 
cures with high potencies of ipecac, I do not think the same can be 
said of lobelia, for it seems to have some power of relaxing the bron- 
chial spasm without causing nausea. Salter, however, ranks it with 
tobacco. I have never seen any strictly curative effect from the 
medicines mentioned in Arndt's ;i Practice " or " LilienthaTs Ther- 
apeutics," except the following : 

Aralia, introduced by Dr. S. A. Jones, has been of undoubted 
benefit in hay asthma, but not in true asthma. 

Cuprum is of real value in uncomplicated spasmodic asthma, i.e., 
when the spasmodic character over-shadowed all the other phenomena, 
and were not local but extended all over the body, especially to the 
hands and feet. 

Case. — Xearly forty years ago, during the first years of my prac- 
tice, I was called to see a woman aged twenty, and when I arrived 
she was suffering the agony of a paroxysm of spasmodic asthma. 
She was very fat (adipose), and was supposed to have heart disease. I 
found her sitting in a chair, her hands grasping the arms, her face livid 
and bloated, her eyes protruding, and laboring fearfully for breath. 
The heart was beating violently but irregularly : these attacks had 
appeared daily or nightly for several weeks. She had been vomited 
with lobelia, and had been dosed excessively with other drugs. She 
presented such a complete picture of cuprum symptoms that I gave 
her cuprum metalicum 6x trituration, a grain every half -hour. In a 
few hours the paroxysm subsided. The medicine was continued every 
three hours, and for several days she was better, after which the par- 
oxysms recurred. Then I tried arsenicum 3x with the same results. 
Still believing cuprum to be the remedy, and mistrusting the value 
of the metallic copper, I decided to try the arsenite of copper, 
although I had never heard of it being used as a medicine. Pro- 
curing the crude drug I made a lx trituration, and prepared it for 
use by dissolving two or three grains in eight ounces of water, 
directing a teaspoonful of it to be given every three hours. Four 



300 THE PRACTICE OF MEDICINE. 

days afterwards I saw the patient and found her cured. She had 
no attacks until six months after, when the same medicine cured 
promptly. I believe I was the first to use this drug in medicine. 
Since that time I have cured many cases of asthma with it. (I 
afterwards examined the woman's heart, but found no lesions.) 

Cannabis indica, cocculus, moschus, platina, sabal, and asafoe- 
tida, will cure only hysterical asthma. I will now mention some 
indigenous drugs that have attained considerable reputation in 
asthma. 

Eucalyptus, grindelia, euphorbia pilulifera, enothera, guarana, 
piscidia, lippia, quebracho, hoangnan, yerba-santa, and silphium. 

When profuse bronchorrhoea has been checked by a cold, and 
asthmatic attacks are impending, eucalyptus, by restoring the expec- 
toration, will prevent them. It is a grand remedy for arrested 
discharges from mucous surfaces. In this respect it is a rival of 
gelsemium. 

Euphorbia pilulifera was first introduced as a remedy for asthma 
by Dr. Matheson of Queensland. The natives make a decoction by 
boiling a " handful " of the herb in two quarts of water until the quan- 
tity is reduced to one quart. This is given in small quantities until 
the patient gets relief. Dujardin-Beaumetz, who experimented with 
this drug on animals, says it causes death in the same manner as does 
section of the pneumogastric. It kills them by arrest of the respir- 
atory movements and the cardiac pulsations. It seems to act directly 
on the respiratory and cardiac centres. It gives relief to dyspnoea 
caused by spasmodic asthma, by its action on these centres. In the 
" Pharmacology of the Newer Remedies," several hundred cases of 
asthma are reported, in all of which the use of this drug was attended 
by very favorable results. Nearly all these cases were typical, and 
nearly all had some emphysema. They had teasing cough in par- 
oxysms, nocturnal attacks of all degrees of severity, could not lie 
down in bed, wheezing respiration all the day ; the expectoration was 
viscid, muco-purulent, frothy, and ropy. Nearly all had chronic 
bronchitis. All the patients had been dosed with iodide of potas- 
sium, ipecac, lobelia, antimony, and many other remedies, without 
good results. There could be no error about its prompt effect, for 
many were relieved in half an hour after taking the first dose, and 
when given during the day (ten drops every two hours) the usual 



DISEASES OF THE RESPIRATORY SYSTEM. 301 

nocturnal paroxysms were prevented. If given during the paroxysm, 
twenty to sixty drops of the tincture, or its equivalent, were given 
at one dose. It seems to possess anodyne and narcotic quantities to 
some degree. 

QEnothera biennis was at one time praised very highly by Dr. N. 
S. Davis, of Chicago, as a remedy for asthma associated with gastric 
catarrh. He reported twenty cases in which the drug acted very 
efficiently. Other physicians reported cases of hay asthma, and 
angina pectoris, in which it gave good results. The dose was fifteen 
to thirty drops every three or four hours. 

Grindelia robusta is one of our indigenous drugs that is rapidly 
attaining a high position among the remedial agents for asthma and 
its allied diseases. The experiments made in the laboratory of Jef- 
ferson Medical College show that it acts on the motor nerves, first 
by paralyzing the peripheral end, then the trunks, and finally the 
motor centres in the cord. The heart is slowed because of an 
increase of inhibition, due to stimulation of the cardiac inhibitory 
centre, and the blood pressure is raised chiefly by stimulating the 
vaso-motor centre in the medulla. The respiration is increased in 
frequency by its action on the respiratory centre, and also on the 
terminals of the pneumo-gastric in the lungs. It appears to act 
directly on the cerebral cells, causing narcosis. It also increases the 
secretion of urine. Small doses quicken the action of the heart and 
elevate the blood pressure, secondarily slowing the heart, and at the 
same time the arterial tension falls ; large doses dilate the arteries. 
In toxic doses we have in grindelia a cardiac paralyzer. It acts in 
the same manner on the respiratory functions. This gives us a clue 
to its clinical uses which it is well to bear in mind. It is primarily 
indicated in minute doses when there is congestion of the bronchial 
mucosa, with slight expectoration, and some embarrassment of 
breathing, with increased action of the heart and slight fever. In 
large doses it is useful when there is a profuse secretion from the 
bronchi and bronchioles, with impeded respiration ; and later when 
there is abundant expectoration, with violent coughing, spasmodic 
action of the bronchi, and veritable paroxysms of dyspnoea. 

It has been found curative in these conditions in so many instances 
that it is now considered almost specific in true asthma. The par- 
oxysms occur between midnight and 2 A. M., and last several hours, 



302 TEE PRACTICE OF MEDICINE. 

and are attended by a severe convulsive cough. To make matters 
worse the action of the heart becomes weak and irregular, and this 
feebleness of the circulation increases the distress of the patient. 
There is no structural disease of the heart in such cases, but the 
functions of the cardiac centre in the medulla are depressed. It has 
one symptom of importance, a " key-note " which leads to its selec- 
tion : "A fear of going to sleep on account of loss of breath, which 
awakens him." 

(Grindelia squarrosa has exactly the same symptom.) Many 
asthmatics with a weak heart and feeble respiratory nerve centre 
suffer greatly from this symptom. (The secondary effect of strych- 
nine is similar.) Both are of value by their power in small doses to 
stimulate the motor nerve centres of the heart and of respiration. 
It is one of our most trustworthy remedies in cardiac asthma when 
there is impeded aeration, carbonic acid asphyxia, cyanosis, and 
threatened heart failure. It acts on the kidneys also, and I have 
found it superior to digitalis or strophanthus, because while it 
restores the rhythm and force to the heart, it acts on the cough and 
asthma, and encourages the urinary secretion. 

Several hundred cases are well reported in the " Phar. Newer 
Remedies," illustrating its curative action, and what is unusual and 
praiseworthy, the medicine was in most cases given alone, which, 
adds greatly to the value of the clinical reports. It can be pre- 
scribed in tincture, tablets, pills, and fluid extract. The tincture 
should be hydro-alcoholic, for not all its properties are taken up by 
alcohol. It is most acceptable to patients in the form of an elixir, 
or syrup, one drachm to one ounce, the dose varying from ten to 
sixty drops according to the age and nature of the case. In asthma 
I order the selected dose every two hours during the day, and every 
fifteen minutes during the paroxysm, if it recurs. 

Grindelia squarrosa has not been tested in asthma, but it should be 
useful in some cases, as it causes the key-note symptoms of G. robusta. 

Piscidia is useful as a palliative remedy. In several cases after 
the intensity of the paroxysm had decreased, the patient could not 
sleep, and begged for some hypnotic ; morphine and chloral were 
inadvisable owing to a weak heart. Piscidia is not contra-indicated 
in such cases, and I found that twenty drops caused the patient to 
sleep calmly and soundly. 



DISEASES OF THE RESPIRATORY SYSTEM. 303 

Eryodictyon and lippia have been used with alleged success in 
asthma, but the clinical reports are almost valueless, because the 
drugs were used in combination with others. I think I cured one 
case with lippia, and two with eryodictyon, at least they gradually 
improved under their use, until I lost sight of them. 

The diet in cases of asthma, or those subject to it, must be light 
and digestible. No big rich dinners with wines and malt liquors. 
This is one of the few diseases where eating on going to bed is not 
permissible. The last meal of the day should be three hours before 
bedtime. An attack of indigestion is pretty sure to bring on a par- 
oxysm. Strong black coffee drunk on an empty stomach will ward 
off a paroxysm, but if taken after meals, will cause it. Dr. Salter 
has the following remarks on diet in asthma : 

" And now let me say a word or two about those peculiar articles 
of diet that have a special tendency to oppress and tighten the 
breathing of those liable to asthma. They are not the same in all 
cases ; but those that I have found have this tendency most com- 
monly are the following : Anything in anyway preserved, especially 
if strongly impregnated with antiseptics, whether condimentary or 
saccharine, such as potted meats, dried tongue, sausages, stuffing and 
seasoning, preserved fruits, such as one gets at dessert, e. g., pre- 
served ginger, candied orange peel, dried figs, raisins, especially 
almonds and raisins (a vicious combination). Cheese is bad, espe- 
cially if old and decayed ; nuts are worse. With regard to cheese 
I remember hearing an asthmatic remark that there was ' as much 
asthma in a mouthful of decayed Stilton as in a whole dinner.' Meat 
pies are very 'asthmatic,' and so, in a peculiar degree, for some 
reason or other, are beefsteaks and kidney puddings. I have 
known more than one asthmatic condemn them as being very bad. 
Coffee, although of great benefit in some cases as a stimulant, is from 
its indigestibility, especially if taken strong, and with sugar, so 
bad for asthma that it deserves to be classed among its special pro- 
vocatives. I know the case of a gentleman whose dinner making 
him asthmatic or not entirely depends on his taking, or abstaining 
from, the customary post-prandial cup of coffee. Heavy malt liquors, 
especially those containing a good deal of carbonic acid gas, as bot- 
tled stout and Scotch ale, are of all drinks the worst for asthma." 

The selection of climate and place of residence for asthmatics 



304 THE PRACTICE OF MEDICINE. 

depends on several factors. High altitudes are generally recom- 
mended indiscriminately, but this is an error. If emphysema exists, 
such locations do more harm than good. If it is not present, or but 
slight, the high arid regions of Colorado, California, Arizona, New 
and Old Mexico are to be selected. I have known many cases do 
well at Mackinaw, Ashland, and around Lake Superior. All damp 
cold places should be avoided as a residence. I am informed that 
since the introduction of irrigation to a large extent in the West, 
asthmatics do not do so well there. If emphysema is present, the 
Gulf States, particularly lower Florida, are best. I know of many 
confirmed asthmatics who are absolutely free from it so long as they 
remain in Florida, but if they return to the Northern States on a 
visit they suffer from it. The West India Islands are excellent 
resorts. Nothing is more curious than the effect of change on 
asthmatics. Dr. Salter narrates many cases of confirmed asthmatics 
who come to London for advice, or to reside. So soon as they 
reached that city the attacks ceased and never returned. I have 
known a great many persons from country towns or farms come 
to Chicago with reluctance, fearing their asthma would be worse, 
but were delighted to find complete immunity. Dr. Macaulay once 
said, "It is impossible to predict except by trial what air will suit 
an asthmatic. The fact nearest the truth appears to be that what- 
ever air the patient may be in, you should try the exact opposite." 
Dr. Salter mentions many singular instances where patients living 
in the pure air of the country, or in the best part of London, on 
being obliged to remain over night in the smokiest, dustiest, foul- 
est, and closest air of that city, had in such places no attack of their 
asthma. 

I have observed the same examples in Chicago. I have had 
asthmatic patients, born and residing in Denver, come to consult me, 
who, while here, were perfectly free from asthma. 

Sea air will give relief to some asthmatics, while others residing 
by the sea have it all their lives. Dr. Salter concludes his remarks 
on change of air as follows : " Possibly there is no case of asthma 
that might not be cured if the right air could only be found," but 
he says they cannot go back to their original air, or the disease will 
surely recur. 

Dr. Nunes, of Rio Janeiro, Brazil, being dissatisfied with the 



DISEASES OF THE RESPIRATORY SYSTEM. 305 

use of the tincture of lobelia in asthma on account of its nauseous 
taste, which was objectionable to his patients, concluded to test the 
alkaloid lobeline. Dr. Nunes commenced his experiments with the 
administration of lobeline in doses of one-sixth of a grain, given at 
long intervals, while all other treatment was suspended, and gradu- 
ally increased the quantity given until six grains were given to 
asthmatics without producing any toxic effects. The tolerance for 
this large dose of lobeline, claimed by the author to exist in asthmat- 
ics, is attributed by him to the excited condition of the nervous sys 
tern, in which he finds the primary cause of the asthmatic affections 
Lobeline, according to Dr. Nunes, may be administered subcutan 
eously without producing any local reaction, and he advises its use 
in this manner where an immediate effect is desired. The author 
publishes tolerably full notes of nine cases of asthma in which lobe- 
line, in doses varying from three-fourths of a grain to six grains, 
seemed to produce decided relief from the asthmatic symptoms, and 
he terminates his memoir with the following conclusions : (1) Lobe- 
line does not possess the toxic effects generally attributed to it in the 
doses which he recommends ; (2) it possesses no emetic or nauseat- 
ing properties, as is the case in lobelia, and its employment is, there- 
fore, preferable where lobelia is indicated ; (3) he has employed it 
in doses of from three-fourths of a grain to six grains daily for 
adults ; for children, one-sixth to three-fourths of a grain ; (4) it 
has no irritating action on the cellular tissue, and therefore may 
be administered in hypodermic injection, a fact which renders it more 
preferable than the tincture of lobelia ; (5) the evident action of 
lobeline on the nervous system would seem to indicate its employment 
in other convulsive affections, such as tetanus; (6) the cases in 
which he has employed lobeline have remained permanently cured. 

BRONCHITIS. 

There are several forms of this disease, and they differ so much 
in their pathology that they require separate consideration. The 
varieties are : 

(1) Acute Catarrhal Bronchitis ; (2) Chronic Catarrhal Bron- 
chitis ; (3) Capillary Bronchitis ; (4) Dry Bronchitis ; (5) Foetid 
Bronchitis; (6) Croupous Bronchitis. 

20 



306 THE PRACTICE OF MEDICINE. 



ACUTE CATARRHAL BRONCHITIS. 

This is generally but an extension of an acute nasal or pharyn- 
geal catarrh downward through the larynx to the bronchi, but I 
have known many cases in which it commenced in the bronchi and 
extended upward until it ended in the nasal passages. 

The treatment differs but little from that of an ordinary coryza, 
for the same remedies which affect the nasal mucous membranes 
affect similarly the bronchial. The patient, as soon as he feels the 
irritation in the chest, with the cough, the constriction, and soreness, 
should keep in-doors if the weather is cold, and keep the air of the 
room warm, 70° to 75°, and moist. This is important, and can easily 
be done by placing a pan of water on the register or stove, or over 
a gas burner. The water may be medicated by putting in it a few 
drops of iodine, eucalyptol, or terebene. 

Osier (" Practice of Medicine ") mentions the prevalent habit 
among some physicians of prescribing quinine in the beginning of 
such cases, and asserts that its value is very doubtful. I know it to 
be injurious, for I have seen severe aggravation follow quickly after 
the first dose. He protests against the practice of Turkish baths, and 
his experience is like my own, that the worst cases occur after tak- 
ing these baths. 

There are a few medicines which should be added to those men- 
tioned under coryza, namely, iodide of antimony, tartar emetic, ery- 
odictyon, grindelia, phosphorus, and squills. Iodide of antimony is 
particularly useful when the whole chest seems raw, and the con- 
strictive sensation is notable. If the temperature is over 100° alter- 
nate it with aconite. Tartar emetic is useful for nearly the same 
symptoms, but the heaviness on the chest is not a prominent symptom. 

Eryodictyon (yerba santa) is suitable when the harassing cough 
brings up a little glairy mucus, and there is some fever. 

Grindelia is useful in asthmatic subjects who tell us " if this is 
not checked right away it will run into asthma." The cough is at 
first dry, then wheezing without much expectoration. 

Scilla (squills) is one of the most useful medicines in acute bron- 
chitis, because it causes almost identical symptoms, even to the pre- 
ceding coryza. It is much neglected by our school, probably because 
we are prejudiced against it on account of its abuse by our old-school 



DISEASES OF THE RESPIRATORY SYSTEM. 307 

colleagues, mothers, and nurses, who give it in nauseating and 
pathogenetic doses. Hahnemann says its primary effect is to increase 
the secretion of the bronchial glands and cause profuse expectoration, 
but its secondary to dry it up, causing fever and painful cough with no 
expectoration, L e., if used in large doses. I shall refer to its dangers 
when treating of capillary bronchitis. In catarrhal bronchitis the low 
dilutions are very useful, preventing profuse expectoration. One indi- 
cation for scilla often guides me in its selection — the profuse watery 
urine which scalds. This in children often accompanies acute catarrh 
of the bronchi. 

Phosphorus is so favorably known in this disease that I need 
only mention it. The soreness and rawness in the chest is the guid- 
ing symptom. 

.ZEsculus, bryonia, hyoscyamus, hepar sulphur, iodine, drosera, 
sticta, sanguinaria, spongia, sulphur, lobelia, jaborandi, ipecac, co- 
cillania, and euphorbia pilulifera are all useful. The two last resem- 
ble ipecac and squills. (See " Pharmacology of the Newer Materia 
Medica.") 

CHRONIC BRONCHITIS. 

Definition. — A slow, subacute form of inflammation of the 
mucous membrane lining the bronchial tubes, tending to recur 
from various exciting causes. It is generally a disease of adult 
life, rarely occurring in children except after measles and whoop- 
ing cough. The majority of cases occur in old people ; men are 
more subject to it than women. It has most of the symptoms of 
the acute form, the substernal pain, dyspnoea, cough, and expectora- 
tion. Its various manifestations have received the following names : 
bronchial irritation, bronchorrhcea, winter cough, and fcetid bron- 
chitis. 

" Winter Cough " is the commonest variety. The patient does 
not cough much during the summer, but in the fall, when cold and 
dampness set in, slight paroxysms occur, which gradually become 
more severe as the season advances, and the coldness and dampness 
increases. The coughing is usually worse at night, and when the air 
is loaded with dust and vapor. The expectoration may be scanty 
and mucous, or profuse and muco-purulent, white, frothy, gray, 
slate-colored, yellow, green, and sometimes streaked with dark blood. 



308 THE PRACTICE OF MEDICINE. 

There is but little fever, and then a rise of only a degree or two 
towards evening. There is not much emaciation and the digestive 
processes are not much deranged. If the patient is asthmatic the 
dyspnoea is considerable until the expectoration is free. Biliousness 
aggravates the disorder. 

" Dry Cough " is but another form, in which the expectoration 
is scanty owing to some obstacle to the secretion of mucus. The 
irritation may be so intense as to excite severe paroxysms similar 
to whooping cough. They cause great soreness in the chest and 
inter-costal muscles. 

" Bronchorroea " generally occurs in old men and women. The 
paroxysms are very severe, not as in dry cough, because of the 
scanty expectoration, but from the opposite — the great quantity of 
secretion. This may be enormous, as much as four or five pints 
daily, and it is tough, stringy, tenacious, and may be frothy and 
bloody when the expulsive efforts are severe. The patient will not 
cough as much at night as would be supposed, but he commences in 
the morning after eating, and the effort to dislodge the mucus often 
causes vomiting of food. Sometimes the cough commences on ris- 
ing, and a pint or more is expectorated before breakfast. 

" Foetid Bronchitis " does not differ essentially from bronchor- 
rhoea, except as to the offensive odor, which is probably caused by 
the decay of crypto-organisms, sporules, or fungi, in the dilated 
tubes. The breath of the patient is generally foetid. There is some 
fever of a hectic character, followed by night sweats in debilitated 
subjects. This variety is often supposed to be caused by vomicae or 
cavities in the lungs. 

Treatment. — Before entering into a consideration of the medi- 
cines to be selected as curative remedies we will inquire into the 
action of drugs on the bronchial tubes and their lining membranes. 

A large number of drugs will cause cough, but in different ways. 
A few cause it by their irritant action on the nerves and their per- 
ipheral endings in the bronchial mucous surfaces. These drugs 
rarely cause primarily any expectoration. When the expectoration 
appears it is secondary, owing to the bronchial irritation excited by 
coughing. These medicines are aconite, arnica, arsenic, belladonna, 
hyoscyamus, lactuca virosa, lachesis, naja, stramonium, agnus, cal- 
abar, cannabis, causticum, codeine, quinine, morphine, opium, con- 



DISEASES OF THE RESPIRATORY SYSTEM. 309 

ium, cuprurn, drosera, kalniia, laurocerasus, nux vomica, cenantlia, 
phellandriuni. The cough is always at first dry, continuous, or par- 
oxysmal. The expectoration is secondary, with the nervous element 
persistent. These drugs nearly all cause an actual dryness of the 
mucous membrane. If a cough with profuse expectoration suddenly 
changes to a dry cough, it is because congestion or inflammation has 
set in. Quinine or opium will check a profuse expectoration by 
producing a dryness and congestion that arrests secretion. After 
the dryness and congestion subside, expectoration sets in as a reac- 
tion of the organism to restore the normal mucus, but the reaction 
sometimes goes beyond that, and abnormal secretion obtains. 

In the treatment of dry coughs the pathogeneses of the above 
medicines must be consulted in our " Materia Medica," aided by 
such repertorial works as Dr. E. IT. Jones on "Dry Cough" (now 
I fear out of print), or "Worcester's " Cough and Expectoration." 
In prescribing them homeopathically we should avoid giving doses 
large enough to cause dryness of mucous surfaces, but just enough 
to act as a sedative to the nerve-endings in the bronchi. If the 
previous element is coincident with a loose cough, the dose may be 
larger than in the dry variety. Rarely if ever should morphine or 
opium be given to suppress a cough suddenly, be it loose or dry. 

Instead of the special indications for each medicine, I will give 
my experience with those that have yielded me the best success. It 
is certainly the experience of my readers that in the treatment of 
obstinate cough, the patient often clings to the old-established cus- 
tom of the use of " cough syrups," lozenges, and "cough drops." If 
we do not prescribe our medicines in some such form they will openly 
or secretly purchase some one of the proprietary medicines or nos- 
trums kept by all druggists. If they were all harmless it would not 
so much matter, but as all contain opium in some form they derange 
the stomach and nervous system, and often lead to the opium habit. 
These nostrums also generally contain tartar emetic or ipecac, which 
set up gastric irritation. Is it not more professional for us to insist 
on prescribing syrups and lozenges after our own formulae ? "We can 
do this without violating our law of cure, or our pure pharmacolog- 
ical methods. 

Pure syrup made from cane sugar, rock candy, or licorice sugar 
is as legitimate as sugar of milk. It is a fact that medicines given 



310 THE PRACTICE OF MEDICINE. 

in these vehicles often act better than in cones, powders, or water. 
The most satisfactory remedy for a dry, nervous cough is hyos- 
cyamus, when the mucous surfaces are dry, or when there are par- 
oxysmal attacks of cough severer than the amount of expectoration 
warrants, and when the cough is worse at night and will not allow 
sleep. A few drops or discs of the 2x or lx dilution often act 
admirably, but not always. In children and old people, who bear 
and require larger doses of this drug, it is often necessary to give 
two to ten drops of the tincture several times during the day, and at 
night. The following formula has been very successful : 

1^ Tincture hyoscyamus drm. ii. 

Syrup rock candy oz. iv. 

Dose, one teaspoonful. 

If a lozenge is thought more convenient any good druggist can 
prepare one : 

ly Extract hyoscyamus gr. v. 

Extract licorice gr. xxv. 

Sugar of milk gr. xxv. 

Make fifty lozenges ; dose, one every two or three hours. 

For the severe nightly paroxysms of old people, five lozenges on 
going to bed is not too large a dose. 

In testing the value of hyoscine and hyoscyamine, I found that 
the 1-500 grain (tablets), repeated every few hours, had about the 
same effect on cough as five or ten drops of the tincture. 

Next in value I estimate lactuca virosa. This is not the common 
garden lettuce, for cultivation has deprived it of nearly all its medi- 
cinal qualities. It is prepared in France, in the Province of Limoyne, 
from the lactuca virosa altissima (gigantica), supposed to be the an- 
cestral plant of the edible lettuce. The milky juice is used, which is 
obtained by making incisions in the stalk at the time of flowering. 
It has been supposed that its effects were like opium, but so mild 
that it was banished from the regular Materia Medica. Aubergier, 
of France, rescued it from disuse by preparing it from the gigantic 
lettuce, cultivated under his directions. Lactuca elongata, an indi- 
genous American species, grows wild to the height of six or eight feet, 
and has an abundance of milky and very bitter juice. It ought to be 
more medicinal than European species. T. F. Allen says (" Ency- 
clopedia Materia Medica," p. 487), " It is now used in making lac- 
tucarium." The most elegant preparation is the syrup of lactuca- 



DISEASES OF THE RESPIRATORY SYSTEM. 311 

rium prepared by Aubergier, of Paris. I see no reason why our 
pharmacists cannot make a syrup equally elegant from our native 
species. A study of its symptoms shows it to resemble hyoscyamus 
more than opium. In fact it has lately been discovered that it con- 
tains hyoscyamine. The following are the guiding symptoms of lac* 
tuca : " Incessant spasmodic cough which threatens to burst the 
chest, always caused by a peculiar tickling in the fauces, which in 
turn seem to be produced by a sense of suffocation in the throat. A 
too large dose changes an easy loose cough to a dry barking and 
painful one." " Dry cough in short paroxysms, with shaking of the 
chest and shocks in the occiput ; hollow dry spasmodic cough. Great 
tightness in the lower portion of the chest. Wakes suddenly at night 
with anxious tightness of the chest." Lilienthal says " the cough is 
caused by a spasmodic irritation of the nerves of the larynx and 
pharynx." A copious mucus expectoration appears when the cough 
has lasted a long time (secondary effect). 

Discs saturated with the tincture or lx are often efficient, but I 
prefer the syrup made from the extract, or a good tincture of lactuca 
elongata. Teaspoonful doses, from a mixture of one drachm of the 
tincture or one grain of the extract to an ounce of syrup, four times 
a day, and as often at night, soon control the worst cases. If given 
for the frequent, deep-seated, convulsive cough of consumption that 
prevents sleep and eating, it keeps it under control, making the suf- 
ferer quite comfortable. As the symptoms indicate, it is useful in 
whooping cough, and the cough of nervous asthma. I know of no 
cough remedy so pleasant and grateful to children, for those aggra- 
vating nocturnal and often diurnal coughs which by their persistence 
and strident noisiness madden the whole household. Here Auber- 
gier's syrup is a great boon. In incurable consumption I often add 
five or ten grains of phosphate of codeine to each four ounces. If 
we must use opium at all as a palliative in obstinate cases, codeine 
is the best form, in doses of one-tenth or one-fifth grain. 

A good formula for a mere palliative is : 

1^ Paragoric oz. ii. 

Chloroform water oz. i. 

Syrup oz. i. 

A teaspoonful every hour or two. 

Belladonna can be prescribed in the same manner as hyoscyamus, 
giving about one-half the dose. 



312 THE PRACTICE OF MEDICINE. 

Ambergris somewhat resembles lactuca. It is an excellent rem- 
edy for purely nervous spasmodic cough in hysterical children and 
women. 

Apis causes a constant harassing cough, with stinging in the air- 
passages. It may be purely nervous, or due to a watery swelling of 
the glottis, or slight oedema. 

Rumex crispus is the typical remedy for the real dry bronchitis, 
when the hyperesthesia coincides with a scanty expectoration. It 
has several congeners from which to choose. Carroll Dunham's mas- 
terly comparisons of remedies can never be excelled. His only equal 
'in that specialty was the lamented Farrington, while the so-called 
comparisons of Gross and Kent are hair-splitting and illogical. 
Dunham compares rumex with belladonna, lachesis, phosphorus, and 
causticum, and says : " It (rumex) stands preeminent in respect 
to the extreme sensibility of the larynx, trachea, and bronchi ; it 
should be studied." I have quoted his comparisons, showing the 
resemblance and difference of these five drugs, on page 695 of my 
" Therapeutics of New Remedies," and it may be found in " Dun- 
ham's Lectures." The cough of nux moschata, corallium, nickel, 
platina, stannum, and zinc, I believe to be primarily purely nervous. 
The cough of stannum is nervous, and the profuse muco-purulent 
expectoration is a secondary bronchorrhoea, while the bronchorrhoea 
of copaiva and others of its analogues is primarily catarrhal. 

A syrup of the juice found in the leaves and stalks of verbascum 
(mullein) is a good remedy for nervous cough. The cough is deep, 
hollow, hoarse, " sounding like a trumpet," and occurs during sleep 
without waking the child. 

This cough has been mentioned by some authorities as denoting 
sensitive areas in the naso-pharyngeal spaces. The tincture in five 
or ten drop doses or a spray of the extract in water can be used 
with benefit. 

Bronchorrhoea, when it has no predominant nervous element, 
requires altogether different class of drugs which contains oils, oleo- 
resins, or a volatile oil. These medicines act through the channels 
of the circulation. 

Hahnemann and some of his radical disciples teach that the 
action of drugs is dynamic, meaning of an imponderable, immaterial 
force. This theory must be discarded. The idea of a dynamic force 



DISEASES OF THE RESPIRATORY SYSTEM. 313 

is abandoned by all scientists. There is no dynamic force except 
that exerted by the human soul. Medicines, even in the minutest 
quantity, act on the animal organism by means of their ultimate 
molecules coming in contact with the various tissues of the body. 
The medicines alluded to in the foregoing observations are of that 
class, principally from the vegetable kingdom, known as " expecto- 
rants." They are abies, ammonium, antimony, arum, asafcetida, 
bryonia, coccus cacti, cocillaria, chekan, copaiva, cubebs, eucalyp- 
tus, euphorbia pilulifera, gurjun, lippia, lobelia, niyrtus, Pulsatilla, 
sambucus, sanguinaria, scilla, senega, senecio, sabal, silphium, tur- 
pentine, tartar emetic, balsam of tolu, and balsam of Peru. All the 
iodides belong to this class. All these drugs, when taken into the 
stomach, are absorbed, carried through the system, and excreted 
through the skin, respiratory organs, and kidneys. They pass out 
in the sweat, urine, breath, and feces, but their main exits are through 
the bronchial and renal mucous surfaces. Those of the above that 
contain volatile or fixed oils, namely, abies, asafcetida, chekan, gur- 
jun, copaiva, cubebs, eucalyptus, myrtle, balsam of Peru, sabal, sene- 
cio, erigeron, cajuput, turpentine, silphium, and others, can be dis- 
covered by their odor in the expired air of the patients, even when 
given in small doses. This quality makes them especially valuable, 
for in passing out of the body they pass through the diseased tissues, 
and act better than if sprayed upon them. 

The other medicines of that class have the same exits, but do 
not change the odor of the breath, although they are found in the 
expectoration. If any of my readers suppose that they act through 
the nervous system, let him dismiss the idea ; the action of all of 
them is due to the fact that their atoms or molecules pass over and 
through the diseased tissues. 

Brief indications of these medicines must suffice. 

Abies. The spruces contain an oil analogous to turpentine, and 
have been used in domestic practice for old coughs. 

Allium (garlic) is highly praised by Teste (" Materia Medic a ") 
for bronchorrhoea, and is used for that purpose by the French and 
Spanish. Its guiding symptom is " a morning cough after leaving 
his bedroom, with extremely copious expectoration." " Continual 
mucous rales in the bronchi, and great difficulty in expectorating a 
glutinous mucus, with oppression of the chest at night." 



314 THE PRACTICE OF MEDICINE. 

Asafoetida has similar symptoms, and I have found it very suc- 
cessful in old people who have bronchorrhoea and are nervous and 
hysterical. A pill of one or two grains every three hours acts very 
satisfactorily. 

Copaiva for a profuse, muco-purulent, easy expectoration, is one 
of the best medicines that I ever used. I once reported eight cases, 
which had been pronounced consumption, all cured in a few weeks 
with ten to fifteen drop doses of equal parts of balsam and alcohol. 
I now use it on sugar discs, each one containing two minims, or in 
the capsules which contain five to ten drops. From ten to sixty 
drops can be given daily without causing nausea or a rash. 

Cubebs has different symptoms. The expectoration is more 
difficult, and is composed of stringy white or gray mucus. The 
dose of the oleo-resin is the same as that of copaiva. 

Cajuput oil is used by the natives of India for chronic bronchitis. 

Dipterocarpus (Gurjun balsam) is obtained from a tree in east- 
ern India. It resembles copaiva in medicinal action, but is less 
nauseating and causes no rash. Dr. William Murrell, in the " Lon- 
don Lancet," praises it very highly in chronic purulent bronchitis. 
He prefers to prescribe it in malt (two drachms to four ounces), a 
teaspoonful every two hours. He says it " clears out the chest and 
eases the cough admirably." 

Myrtus communis yields an oil called myrtol, which is said to 
be a powerful germicide and deadly to the bacillus of phthisis. A 
case is reported in our literature where the tincture cured a case of 
" cough with purulent expectoration, with pain from front to back 
in the left chest." I have used myrtol as a remedy in purulent 
bronchitis with foetid expectoration with gratifying results in two 
cases. 

Myrtus chekan is a native of Chili. Its virtues reside in an 
ethereal oil and tannin. The oil is soluble in chloroform, ether, and 
alcohol. I consider this similar to myrtol, and so far as I have used 
it its curative sphere is similar. Dr. Dessau, of the German Hos- 
pital in Valparaiso, speaks very highly of chekan. His attention was 
called to it by the cure of one of his patients with chronic purulent 
bronchitis. He reports many cures of similar cases. Dr. William 
Murrell, of England, who has made a special study of the remedies 
for winter cough and bronchorrhoea, reports using it in fifteen cases 



DISEASES OF THE RESPIRATORY SYSTEM. 315 

of paroxysmal cough with yellow, purulent expectoration, and much 
shortness of breath on exertion : " There was in all cases within a 
few days a decided improvement in the cough ; expectoration from 
the first was easier, soon diminished in quantity, and finally the dysp- 
noea was less." 

A great many similar cases are reported cured by chekan in 
" Pharmacology of Newer Materia Medica." It can be prescribed 
in the dilutions, or the oil on discs or in soft capsules. The myr- 
tols can be used in a steam or hand atomizer in albolene or fluid 
vaseline, and when so applied will greatly aid their internal use. 

Balsam of Peru is an old remedy noticed in "New Remedies." It 
has about the same sphere of action as gurjun balsam. In old, foetid 
bronchorrhcea it has made many cures. It has been my practice for 
years to prescribe the muriate of ammonia and other remedies for 
bronchitis in syrup of balsam of Peru. The syrup is also the best 
method of prescribing the balsam. It should contain two or five grains 
to one drachm. The addition of one drop of chloroform to each tea- 
spoonful increases its curative action. There is nothing peculiar 
about the cough. The expectoration is purulent, profuse, and foetid 
as if it came from a vomica or pus secreting surface. Balsam of 
tolu has similar curative powers but in less degree. 

Eucalyptus and eucalyptol have long had a deserved reputation 
in chronic and foetid bronchorrhcea. The first notice of this drug 
in this country referred to its value in foetid expectoration from any 
cause. Now it has an established reputation for many chronic 
bronchial diseases. The tincture was at first used in doses of one 
drachm or more. The special guiding symptoms of the cough have 
not been ascertained by provings, but that is not essential. The 
principal indication is the profuse muco-purulent expectoration, loss 
of weight and appetite, and night sweats. I know of no medicine 
which acts as favorably in such grave cases. It can be used in the 
tincture, on discs, or in syrup (five drops to the ounce), or as the 
" eucalyptol water," prepared according to my method, one drop to 
the drachm, with one drop of chloroform. Used as a spray or vapor 
greatly adds to the effect of its internal use. 

Oil of erigeron or oil of senecio is indicated when the expectora- 
tion contains bright arterial blood. 

Oil of sabal serrulata is gaining a good reputation in bronchor- 



316 THE PRACTICE OF MEDICINE. 

rhoea, especially when combined with syrup of the hypophosphite of 
soda. An excellent preparation of this oil of saw palmetto is with 
maltine — one drachm to each ounce. In doses of one or two tea- 
spoonfuls or a tablespoonful, I have seen a chronic bronchitis dis- 
appear in a few weeks, with rapid increase of the weight of the 
patient. It has all the fattening power of cod-liver oil, with other 
valuable properties added. No medicine has a more favorable influ- 
ence over defective assimilation of foods, or imparts greater vigor to 
the organs of reproduction. The " saccharated oil " is also an excel- 
lent preparation in doses of one drachm. 

Silphium is a valuable medicine when the bronchorrhoea is asso- 
ciated with asthma. The expectoration is viscid, tenacious and 
often offensive, and the chest feels better when the expectoration is 
profuse. 

Turpentine is a remedy almost as old as medicine. It was used 
by the ancients from prehistoric times. It once had a great reputa- 
tion in the third stage of pneumonia, when the expectoration was pro- 
fuse and purulent. Of late years its derivations — terebene, ter- 
pene, and terpin hydrate — have taken its place and are extensively 
used. 

All these are typical expectorants. Given in medicinal doses 
they cause an increased secretion from the bronchial and laryngeal 
mucous membrane, at first thin, afterwards thick and yellow or green. 
If massive doses are given the lungs become congested and the secre- 
tion is arrested, with dry and painful cough and bloody expectora- 
tion. They are homeopathic to all stages of bronchitis. The dose 
should be varied with the amount of inflammation and expectora- 
tion. If the latter is very profuse, muco-purulent, and offensive, give 
small doses of the crude drug. If there is scanty, bloody sputum, 
with tightness of the chest and painful cough, the 3x is strong 
enough. 

Terebene is a clear colorless liquid, with an agreeable odor like 
pine shavings. It is an oil not miscible with water, but can be pre- 
scribed on sugar discs, or in chloroform water, and used in albolene 
as a vapor. 

Dr. Murrel gives the following indications for its use : " In cases 
where there is emphysema, and the ailment has been present for 
some time, it may be for some years, with the following symptoms : 



DISEASES OF THE RESPIRATORY SYSTEM. 317 

cough very troublesome, and sometimes even violent ; expectoration 
tough and adhesive, or it may be easy and copious ; great shortness 
of breath and rawness of the chest ; sleep broken and general health 
much disturbed. The beneficial effects of the medicine do not mani- 
fest themselves for some little time, and not infrequently the dose 
has to be increased to ten, or even fifteen drops. If, however, the 
drug be persevered with faithfully and regularly, the cases are few in 
which I have to record a failure. Altogether I consider pure tere- 
bene one of the most valuable remedies at our command in the above 
class of cases." 

Terpin hydrate is in the form of white greasy crystals, resem- 
bling spermacetti. It can be triturated with granular sugar of milk, 
but is best given in tablets or capsules. It is said to resemble the 
union of turpentine and creosote. It is tasteless and can be given 
to children without difficulty. 

In the winter of 1890 I made considerable use of it in the bron- 
chial form of grippe in children and adults. The expectoration was 
profuse and difficult to raise from the bronchi, causing painful 
wearying cough. I found that the lx in two-grain doses acted well 
in young children, lessening the coarse rales and the cough. For 
adults the pills of one grain each, one every two hours, acted equally 
well. Dr. Murrell now prefers this to terebene for internal use, and 
praises it very highly. In an article by Dr. Halsted Boyland ("New 
York Medical Kecord," Sept. 24, 1887), hydrate of terpin is highly 
spoken of. He gives the case of a lady suffering from obstinate 
bronchitis, and says, " After two doses (of three grains each) there 
was already an amelioration in my patient's condition ; the cough 
began to loosen ; expectoration became free and easy in consequence 
of elimination by the bronchial mucous membrane ; the skin became 
soft, moist, and natural ; and there was a marked diminution in the 
bronchial whistling and rales." In another case, one of catarrhal 
congestion of the larger bronchi, treated as in the preceding case, 
" there was a notable decrease of the mucous rales ah initio, and 
normal vesicular murmur could be distinctly heard in a very few 
days after." Other cases, such as nasal and pharyngo-laryngeal 
catarrh from cold, have been treated with equal success. In night 
cough from habit, two grains of terpin exhibited at bedtime had a 
good effect. 



318 THE PRACTICE OF MEDICINE. 

Oil of sandal- wood has a specific action on the bronchi as well as 
on the renal passages. In a case of a lady who had chronic bron- 
chorrhoea, with cystic catarrh, and presenting the peculiar " aching 
in the region of the kidneys " so characteristic of this drug, I gave 
discs medicated with the oil diluted one-half with alcohol, one every 
two hours. In a week she came to report that all her catarrhal symp- 
toms had left her, together with the pain in the back. 

The drugs possessing no volatile oil probably pass out of the 
body partly through the bronchial mucous surfaces. Some of them 
have been found in the sputum. 

Muriate of ammonia, crude antimony, tartar emetic, bryonia, coc- 
cus cacti, cocinala, euphorbia pilulifera, lippia mexicana, sanguin- 
aria, chelidonium, squills, pulsatilla, hydrastis, sambucus, and iodine 
all cause an increased secretion from the bronchi. 

Muriate of ammonia is considered almost specific for bronchor- 
rhoea by some physicians. It is named a " stimulant " expectorant, 
and old-school authorities warn against its use when there is much 
congestion but no expectoration. They know that even small doses 
of it will sometimes aggravate. Now this is the very reason why it 
is useful in congestion and inflammation of the bronchi. The 3x 
trituration, alternated with bryonia, is excellent treatment in the dry 
stage of bronchitis, especially in children, as well as in adults. It 
resembles bryonia in many respects in its action on the liver and 
muscular tissues, and they always act well together. Both have the 
dry shaking cough, difficult expectoration, and soreness in the inter- 
costal muscles. After the acute stage has passed and the secretion 
has become profuse, glairy, and tenacious, they should be used 
stronger, bryonia in the lx and muriate of ammonia in one to three 
grains of the crude drug. An excellent prescription is : 

1^ Muriate of ammonia drm. i. 

Fluid extract glycyrrhyza oz. ii. 

Syrup of tolu oz. viii. 

A teaspoonful every four hours for adults, and fifteen drops for children. 

Arnica may be substituted for bryonia in cases where it is almost 
impossible to expel the secretions, owing to the soreness and weakness 
of the muscles of the chest. 

Antimony and tartar emetic, while they are depressing in their 
action on the general system, act similarly to ammonia on the 



DISEASES OF THE RESPIRATORY SYSTEM. 319 

bronchi. I prefer the iodide to the crude antimony or to tartarized 
antimony ; especially when the bronchitis is an extension from an 
acute catarrh of the upper air-passages. If the bronchitis originates 
below, tartar emetic is better. Both are indicated in the congestive 
dry stage, when there is great oppression of the chest, difficult, 
short, " grunting " inspiration, with slower expiration, a sensation of 
internal soreness of the chest, and external tenderness, when " chil- 
dren cry and breathe harder, if you attempt to move them." In 
this stage the 3x of each is sufficient, but in later stages and in 
chronic bronchorrhoea, both are useful when the bronchi are loaded 
with mucus and when coarse rales and bubbling are heard all over 
the chest, and great relief follows free expectoration ; the 2x of either 
in children, and the lx in old persons, act magically in causing free 
expectoration, easy breathing, and a general feeling of comfort. 

Coccus Cacti. — The cochineal insect feeds on nearly all species 
of cactus, and as I asserted in my " Report on the Cacti " to the 
American Institute, 1890, has in consequence many of the medicinal 
qualities of cactus. In many cases of bronchorrhoea the heart's 
action is weak, irregular, and irritable. Coccus admirably meets both 
conditions. It is par excellence, the remedy for the cough of drunk- 
ards, or those patients that are saturated with the catarrhal poison. 
There is a remarkable number of bronchial symptoms, of which the 
following are typical : " Great rawness of the air-passages with 
enormous collection of mucus, which is albuminous, tenacious, viscid 
like the white of egg, or in small lumps ; cleaning the teeth pro- 
vokes cough. The effort of hawking to expel the mucus causes 
vomiting of slime. The respiration is difficult ; voice rough and 
hoarse ; speaking causes vocal fatigue ; worse at 10 p. M. and 6 A. M.; 
cough causes violent palpitation, etc." The dose is ten to twenty 
grains of the lx of the powdered drug every four or six hours. 

Cocillana. — This is probably the drug mentioned in " New Rem- 
edies " as guarea. All the species have a specific action on the air- 
passages. It is a native of Bolivia, where it is used as a cathartic, 
emetic, and expectorant by the natives. It is a powerful drug ; the 
decoction from " a piece of bark two inches square " is considered 
the maximum dose, while a decoction from a piece as large as a 
man's hand has caused death in many instances. It causes " vio- 
lent sneezing and discharge from the nose. Expectoration from 



320 THE P MAC TIC E OF MEDICINE. 

fauces and throat very profuse, which passed off leaving the throat 
very dry, bright red, with a line of demarcation very marked at 
the region of the uvula." Its general action resembles ipecac, but is 
more intense. Inhalation of the dust causes coughing and asthmatic 
breathing. Extensive clinical experiments with this drug in bron- 
chitis, acute and chronic, and in diseases of the throat and lungs, 
have been made by Drs. Stuart and Wilcox in hospitals, and pub- 
lished in " Pharmacology of the Newer Remedies," by George S. 
Davis, Detroit. They will amply repay a careful study. The drug 
should be proven by our school. I quote one of the many cases in 
which it acted promptly as a curative agent : 

" Chronic bronchitis, aged thirty-four, physician, had had cough 
with muco-purulent expectoration for two and one-half months, when 
he began treatment with cocillana in April last. Had been in the 
hands of a brother practitioner, who had prescribed various remedies 
without benefit resulting. Cough had become so troublesome at 
night that it prevented himself and others from sleeping. Night 
sweats and complete anorexia were present. The bronchitis seemed 
at its worst when cocillana was begun. Ten minims of the fluid 
extract were taken three times a day. The cough ameliorated much 
at the end of the first day, and a comfortable night was passed. 
During the second day he was caught in a heavy shower and thor 
oughly drenched, and remained in this condition an hour. As a 
result, a severe spell of coughing occurred on rising the following 
day. Cocillana was continued through that day, and in the evening 
the cough had quite ceased and the lungs seemed as comfortable as 
they had ever been. By the sixth day of treatment, cough had 
entirely disappeared. A noticeable gain in strength was apprecia- 
ble, no doubt due to improvement in his general condition. Night 
sweats had ceased, and increase in appetite had been immediate and 
great. The latter was thought to be the direct effect of cocillana, 
as it appeared shortly after taking the first dose and seemed affected 
by each succeeding one. Cocillana was discontinued at the end of 
a week, he feeling well and there being no recurrence of cough. 
After several weeks of immunity, the cough gradually returned, 
though not sufficient to cause any degree of annoyance except during 
one or two days, when a fresh cold was caught. Believes that a 
regular and persistent use of the drug would have affected a cure." 



DISEASES OF THE RESPIRATORY SYSTEM. 321 

Euphorbia pilulifera is a native of the West Indies, Mexico, and 
Australia. It was first noticed as a remedy for asthma. Its active 
principle is a gum-resin. Dujardin-Beaumetz concludes from his 
experiments that it acts on the pneumogastric and on the medullary 
centre rather than on the nerve itself. It is indicated when an 
attack of bronchitis runs into spasmodic asthma, or in chronic bron- 
chitis, when the dyspnoea is out of proportion to the amount of mucus 
in the bronchi. I have mentioned this drug under Asthma. 

Lippia is a native of Mexico, Cuba, Central America, and Colom- 
bia. It contains an etherial oil — lippiol. It has a pungent odor 
resembling pennyroyal or camphor. The natives of these countries 
use it as a stimulating expectorant. 

Dr. I. J. M. Goss, of Atlanta, Ga., writing of it says : " In the 
4 Pharmacology of the Newer Remedies ' will be found extensive 
clinical reports of its use in coughs, colds, and chronic bronchitis, all 
favorable. It is certainly worthy a thorough investigation." 

Sanguinaria and chelidonium belong to the same family as the 
poppy. Both act as irritants of the liver, lungs, and bronchi, and 
one of their constituents is a yet undiscovered anodyne principle, not 
morphine. I suspect it is more like hyoscyamine. Their action on 
the liver, lungs, and bronchi is similar. They cause a bilious diar- 
rhoea, yellow and thin. Now it is well known that during the pro- 
gress of bronchitis, children often have this bilious diarrhoea, but 
while the diarrhoea of chelidonium is very bright yellow, and does 
not relieve the cough, that of sanguinaria, which is also bright yel- 
low, is followed by a relief from the coryza, cough, or bronchitis. 
Both affect the right bronchi more than the left. The cough of 
chelidonium is more spasmodic, that of sanguinaria more continuous. 
Chelidonium causes a larger amount of mucous rales than sanguin- 
aria. Chelidonium has painful stitches in right side ; sanguinaria a 
general rawness inside, and tenderness outside the chest. Both have 
stitches in the right hypochondrium. 

Senega is especially indicated in the bronchorrhoea of old people. 
The expectoration is composed of thick or watery mucus expelled 
with difficulty, great sensitiveness of the walls of the chest when sneez- 
ing or using the arms, and a tendency to diarrhoea; the stools are 
thin, watery, colorless, and spurt out with force. It should be more 
often used in catarrhal bronchitis of children. 

21 



322 THE PRACTICE OF MEDICINE. 

Squills causes a bronchitis with profuse, thin, viscid, white, or 
red (bloody) expectoration. The cough is worrying, day and night, 
at one time sounding loose, at other times dry ; drinking brings on 
cough. It irritates the urinary organs and causes profuse flow of 
watery urine with strangury (such as children often have with bron- 
chitis). The bronchitis is attended by great prostration, due to its 
depressing action on the heart. For this reason it is dangerous in 
the large doses used in the old-school and domestic practice. It is 
a heart poison and its indiscriminate use has killed many children. 
The dose to a child under five years of age should not exceed a drop 
of the lx every hour or two. Squills, like all drugs, is especially 
adapted to children and old people ; very old people have a similar 
bronchitis ; they cannot expectorate owing to weakness of the heart 
and chest muscles ; their urinary organs are at the same time irri- 
table. 

Pulsatilla affects the bronchial as it does other mucous membranes, 
causing a profuse thick yellow discharge. In women when a bron- 
chitis sets in after suppression of the menses, or at the change of 
life, pulsatilla is an excellent remedy. 

Sambucus has peculiar symptoms (see " Spasm of the Glottis "). 
The secretion is very abundant, causing " suffocative catarrh " of 
the old authors, with heat, attended by profuse sweating and urin- 
ation. 

Sulphur is indispensable in all chronic bronchial affections, espe- 
cially when there has existed some chronic disease of the skin, and 
when the patient is extremely sensitive to changes of the weather, 
draughts, and contact with damp clothing. I know of no medicine 
so powerful in such cases, unless it is cod-liver oil. If the patient is 
emaciated I usually alternate the two. Cod-liver oil need not be 
given in large offensive doses. Soft capsules containing fifteen 
drops each are now prepared which can be readily swallowed. 
(When these cannot be taken give morrhuol — one grain, in pill.) 
Give a dose of sulphur 2x trituration before meals and a capsule of 
the oil after meals, and continue them for months. They will cure 
old bronchial winter coughs of years duration, sometimes without 
change of climate. 

" Yerba-santa " (eryodictyon) has attained a deserved popularity 
in all catarrhal affections of the air-passages. It is a native of Cal- 



DISEASES OF THE RESPIRATORY SYSTEM. 323 

ifornia, and contains thirty or forty per cent of a gum-resin that is 
the active principle. We have a short but suggestive proving of 
the drug on healthy persons from large doses (five to sixty drops of 
the fluid extract). Primarily it caused a dry, irritating coryza of 
the anterior and posterior nares, fauces, pharynx, larynx, and bron- 
chi, with feverishness like that of an acute bronchitis. (In such 
cases the 2x or 6x should be used.) The provers did not take it 
long enough to get secondary symptoms ; I have, however, seen 
them occur when it was taken to excess. The symptoms indicating 
its use in chronic bronchitis are : bronchorrhoea, with great amount 
of muco-purulent expectoration, sometimes offensive, thick, and often 
streaked with blood. The voice is thick, husky, and is sometimes 
lost. There is much emaciation, hectic fever, and night sweats ; 
a weak pulse ; scanty urine, and oedema of the feet. Auscultation 
shows bronchial tubes dilated, blowing sounds over the whole chest, 
moist rales in the smaller bronchial tubes ; respiration about twenty- 
six. The tongue is broad, relaxed, and pale ; the appetite poor and 
digestion slow. I have cured many patients with the above symp- 
toms ; and there are hundreds of cures on record in eclectic and old- 
school journals of apparently hopeless cases. These symptoms being 
chronic and secondary, the dose should be material in quality. The 
tincture can be given on discs to young children or sensitive adults, 
one every two hours, but I prefer giving it in syrup, or with liquor- 
ice : one ounce of the fluid extract or tincture to three ounces 
of syrup of tolu or glycerine, or aromatic fluid extract of liquorice. 
The dose is one teaspoonful of these mixtures every three to six 
hours. The patient gets fifteen drops of the drug, which is enough 
in any case. 

The iodides are all useful in chronic bronchitis. In the 3x, when 
the cough is dry and irritating ; in large doses when the expectora- 
tion is profuse. 

Iodide of arsenic 2x when there is great prostration. 

Iodide of antimony 2x when tartar emetic is not acting satisfac- 
torily. 

Iodide of lithia 2x when the bronchitis has a gouty origin. 

Iodide of potassium (one grain every four hours) when humid 
asthma is present. 

Topical treatment may be attended with good results. When 



324 THE PRACTICE OF MEDICINE. 

any of the oleo-resins, oils, volatile oils especially, are indicated, they 
should be inhaled in the form of vapor. If no instrument is at 
hand, several simple methods can be adopted. (1) They can be 
dissolved in alcohol, to which a little ether or chloroform may be 
added, and inhaled from a sponge ; (2) mixed with albolene or a 
similar vehicle, and inhaled from a common hand or steam atomizer ; 
(3) if the medicines are not oily or resinous, or chemical in quality, 
they can be mixed with water. I have not mentioned hydrastis as 
an internal remedy because there is no proof that it is taken up and 
carried to the respiratory organs. I believe it can cause catarrhal 
inflammation and irritation by its local action only. If used as a 
spray the fluid hydrastis or fluid hydrastia should be selected. 

In muco-purulent or purulent and foetid bronchorrhoeas, there 
is no remedy that will give such prompt and good results as per- 
oxide of hydrogen ; an eight or ten volume solution inhaled deeply 
will soon cause a change, removing the fcetor and arresting the form- 
ation of pus. This can be alternated with eucalyptol water, or euca- 
lyptol in vaseline, which is a powerful agent in arresting purulent 
discharges. 

If there are evidences of the tubercle bacilli in the sputum use 
myrtol or creosote in the atomizer. Probably the best atomizer is 
one worked by compressed air. 

Diet. — Whatever else the patients eat, they should consume all 
the oils and fats they can digest, and if their digestion is not com- 
plete give plenty of pancreatine two hours after meals 

Clothing should be all wool next the skin, all over the body all 
the year around, and not too heavy ; and the skin should be (in lean 
persons) rubbed with some oil every day in winter. (Cocoa nut, 
cotton seed oil, vaseline, or olive oil are to be preferred.) 

Climate. — Either a cold and dry or a warm and dry climate is 
to be preferred. There is only one exception. The sea air when it 
is warm or hot is very beneficial, as along the Atlantic or Gulf coasts 
of Florida, Cuba, Nassau, or any of the West India Islands where 
there is no malaria. The high, rocky islands, like Jamaica and 
Barbadoes, are favorites with English physicians. They are far 
better than the shores of the Mediterranean, especially the north 
shores. Tangiers and some places on the south shore are very bene- 
ficial. I cannot recommend California, unless the extreme southern 



DISEASES OF THE RESPIRATORY SYSTEM. 325 

part be excepted, and then only in valleys sheltered from the fogs of 
the Pacific. In New Mexico and Arizona patients with chronic 
bronchitis often improve rapidly, and as long as they live there do 
not have recurrent attacks. I have known many cases of bron- 
chorrhoea get well in an amazingly brief time when living in a cli- 
mate where the mercury stood at or below zero for weeks. There 
is some influence in such an air that " freezes out," so to speak, the 
disease in a few days or weeks. 

If foetid bronchorrhcea is due to a fungus, such a climate would 
be just the place to send its victims. 

Mineral waters. — Those of the greatest value are the sulphurous 
and the sulpho-saline. Any of these used continuously and mod- 
erately doubtless have a beneficial effect over all diseases of the air- 
passages. 

Since I have availed myself of Fothergill's suggestion to give old 
men with bronchorrhcea strychnine or nux vomica when the muscles 
aiding respiration and coughing were weak, I have been pleased 
with the results. After taking one-sixtieth of a grain three times a 
day for a week they find they have more power to cough and " raise 
the phlegm." If the heart is weak from dilatation or senile degen- 
eration, give the strychnine and digitalis tablets in the same manner. 

Croupous bronchitis is a rare disease. But few cases have been 
reported. It is always probably an extension of laryngeal croup. 
In the cases reported tubular casts of the bronchi have been thrown 
off. The same treatment recommended for the laryngeal form is 
indicated. 



DISEASES OF THE LUNGS. 

CONGESTION. 

There are two forms of congestion : active and passive. 

Active Congestion of the Lungs. — There is considerable doubt in 
the minds of some authorities as to the existence of this condition as 
a separate affection. Nearly all French writers regard it as inde- 
pendent and primary. English authors regard it as symptomatic. 
American authors generally agree with the English, among them 
Dr. Osier. There is no doubt that active fluxion, or flow of blood, 
occurs whenever there is increased action of the heart, or when the 



326 THE PRACTICE OF MEDICINE. 

external capillary vessels of the body are inactive or contracted by 
cold or vaso-motor spasm. 

There is an associated congestion of the lungs in pleurisy and 
bronchitis. 

The symptoms are simply those described under pneumonia in its 
first stages, namely : the oppression of the chest, cough, dyspnoea, 
chill, followed by fever, and moderate temperature, 101° to 103°. 
The physical signs are defective resonance, feeble breathing, and fine 
rales. But that there is an intense, rapidly fatal congestion of the 
lungs cannot be doubted. I have seen too many cases to allow me 
to have any doubts on the subject. It follows sudden or continued 
exposure to intense cold, or an exposure to a cold rain with a com- 
plete drenching ; or getting chilled after being over-heated from vio- 
lent exertion. Such patients often die in twenty-four or forty-eight 
hours after being attacked. 

In one case where I demanded a post-mortem to sustain my diag- 
nosis, the lungs were found in an intense, almost hemorrhagic, state 
of congestion, with no other lesion. The heart and brain were 
healthy. The patient had ridden thirty miles in a cold rain, and 
was drenched to the skin. Doubtless, had his vital energies been 
powerful enough to withstand the congestion, pneumonia would have 
occurred. 

Osier says that in sudden death from disease of the coronary 
arteries he has seen similar great engorgement of the blood-vessels 
of the lungs. 

Passive Congestion may be divided into two forms: (1) mechan- 
ical, and (2) hypostatic. A mechanical congestion occurs whenever 
there is an obstacle to the return of blood to the heart. It is com- 
mon in affections of the right heart. 

" On post-mortem the lungs are swollen, russet-brown in color, 
cutting and tearing with resistance. On cutting into them they 
show a brownish-red tinge, and the cut surface when exposed to the 
air becomes rapidly of a vivid red color from oxidation of the abun- 
dant hemoglobin. So long as compensation is maintained the me- 
chanical congestion of the lungs in heart disease does not produce 
any symptoms, but with enfeebled heart-action the engorgement 
becomes marked, and there is dyspnoea, cough, expectoration, with 
the characteristic alveolar cells." (Osier.) 



DISEASES OF THE RESPIRATORY SYSTEM. 327 

Hypostatic congestion obtains in fevers, and in a dynamic state 
generally. Then the bases of the lungs are deeply congested, caused 
partly by the recumbent position and partly by an enfeebled heart. 
It cannot be an effect of position alone, for a person with a strong 
heart may remain in bed an indefinite time without its occurrence. 
On percussion at the bases of the lungs there will be found dullness ; 
auscultation shows feeble, blowing breathing and liquid rales. The 
subjective symptoms are few. 

Treatment. — In severe active congestion from exposure to cold 
and wet, the first thing is to warm the body and extremities by 
plunging the feet and hands into hot mustard water, and placing 
hot bottles around the trunk and on the abdomen. Then give 
veratrum viride if the heart's action is violent, one to five drops 
every half-hour until the pulse softens. 

Jaborandi has in some cases greatly aided the action of veratrum 
by flushing the capillaries of the skin and inducing hot perspiration. 
Aconite and gelsemium are useful, and specially indicated in less 
dangerous cases when the congestion has been brought on by great 
excitement, violent exertion, or intense heat. Cactus is a potent 
remedy, one drop of a good tincture or the lx often dissipating the 
congestion in a few hours. Belladonna 3x is also an efficient remedy. 
The congestion of the lungs from mitral or aortic stenosis is pas- 
sive. The blood in the lungs cannot flow into its accustomed chan- 
nels, the pulmonary vessels become distended, and the right ventricle 
becomes dilated and hypertrophied. To remove this congestion we 
must give medicines which will impart sufficient power to the left 
ventricle to overcome the obstruction until complete compensation 
obtains. These medicines are cactus, collinsonia, strophanthus, and 
digitalis, selected according to the indications laid down under Dis- 
eases of the Heart. 

My experience has been, that in the above condition, cactus is 
the most useful remedy. It causes short but strong diastolic con- 
tractions of the left ventricle, and narrows the main arteries. The 
dose is one to ten drops of the tincture. In hypostatic congestion 
the same medicines are indicated, for we have to combat a failing 
heart, but they should be aided by moderate stimulation and nour- 
ishing food. It is in such cases that I advise the alternation of 
cactus or any cardiac tonic, with small quantities of glonoine. My 



328 THE PRACTICE OF MEDICINE. 

reasons will be found in an article on " The Condition of the Heart 
in Pneumonia." 

Congestion of the lungs at the change of life is generally a vaso- 
motor disturbance. It is rarely serious except in plethoric women 
or those suffering from aortic or mitral disease. It is generally 
described as "rush of blood to the chest," or "orgasm of blood 
in the chest." Sometimes it is described as u palpitation with smoth- 
ering." The face, neck, and often the whole upper portion of the 
body are red and flushed. These attacks continue until the final 
cessation of the menses. I have known them to occur for many 
years after ; several cases in women of sixty years have come under 
my observation. 

Lachesis is a singularly effective remedy in some cases, especially 
when there is palpitation and a smothering sensation. Sanguinaria 
is useful when the head feels as full as the chest, and there is some 
pain in the head ; the flushing is worse at the menstrual epoch. 

Amyl nitrite is very efficient in mitigating these attacks, espe- 
cially when the flushing is all over the upper half of the trunk. It 
is not so efficient when inhaled as when taken internally on discs 
saturated with the 2x or 3x dilution. 

Glonoine 3x or weaker is indicated when there is quite severe 
pressure and pain with throbbing in the head, with a sensation of 
constriction or fullness in the chest. 

I never have found sulphuric acid or sepia of much value, but I 
have seen good results follow the use of aurum, silica, and senega. 

Pilocarpine 2x will remove those flushings of the chest and face 
which are immediately followed by profuse perspiration. 



OEDEMA OF THE LUNGS. 

In all forms of congestion of the lungs there is a transudation of 
serum from the engorged capillaries, chiefly into the air-passages 
from the alveolor walls. It is present in inflammation with new 
growths, infarcts, and tubercles. When limited to an affected part 
the name collateral oedema is sometimes applied to it. General 
oedema occurs under conditions very similar to those met with in 
congestion. It is no doubt a terminal event occurring in the death 
agony. It is seen in a typical form in the cachexia?, in death from 



DISEASES OF THE RESPIRATORY SYSTEM. 329 

anaemia, in chronic Bright's disease, diseases of the heart, and cere- 
bral affections. (Osier.) 

An oedematous lung looks watery, pits on pressure, and from the 
cut surface a large quantity of bloody serum flows freely. 

Experiments seem to indicate that the essential cause of oedema 
lies in a weakness of the left ventricle, so that the blood accumulates 
in the lung-capillaries until transudation occurs. This gives us an 
important hint as to preventive treatment (cactus, strophanthus, 
and nux vomica). 

The symptoms are rapidly increasing dyspnoea and cough during 
the course of capillary bronchitis or pneumonia. In Bright's dis- 
ease it comes on very suddenly and may prove rapidly fatal. 

Professor Bourret draws attention to a paroxysmal form in 
Bright's disease. The chief symptoms are parosymal dyspnoea with 
an abundant albuminous expectoration, ending either in death or 
speedy relief. He suggests as the cause of this paroxysm a vaso- 
motor paresis of the pulmonary arterioles. He advises alcohol in 
large doses, hydrogogue purges, poulticing the thorax, and in urgent 
cases the subcutaneous injection of caffeine and ether. This form 
of oedema, and not that in which the left ventricle is failing, is the one 
wherein apium virus is specifically indicated. 

Iodide of potassium in some persons who are very susceptible to 
its influence has caused dangerous pulmonary as well as laryngeal 
oedema, and it may prove a homeopathic remedy in patients that are 
known to be so susceptible ; very small doses should be used, not 
lower than the 2x. 

The pulmonary oedema of arsenic is due to its influence on the 
kidneys, and it may be useful in the paroxysmal form, or it may 
attend a general oedema like that of chronic arsenical poisoning. It 
is indicated by the nocturnal attacks, loss of breath in lying down, 
anxiety, restlessness, and thirst. 

Pilocarpine has been recommended, but I fear it would aggravate 
the condition unless given in very minute doses, because it is so 
exquisitely indicated by its primary effects. It has caused sudden 
pulmonary oedema in doses of one-eighth grain, and one drachm of 
the tincture of jaborandi (of which it is the alkaloid) has caused 
oedema of an alarming character. It causes a sudden flooding of the 
bronchioles with thin albuminous or serous fluid which soon drowns 



330 THE PRACTICE OF MEDICINE. 

the lungs, owing to the inability of the victim to expectorate it fast 
enough. A safe and probably curative dose would be the 3x of 
jaborandi or 6x of pilocarpine. 

Ipecac, euphorbia pilulifera, stibium, senega, squills, lachesis, 
may be indicated. In urgent cases, in men of strong physique, I 
should not hesitate to use elateriun, croton oil, or saturated solution 
of Epsom salts, as in pleural effusions. 



HEMORRHAGE FROM THE LUNGS. 

Pulmonary hemorrhage occurs in two forms : (1) bronchor- 
rhagia, in which the blood is poured out into the bronchi and is 
expectorated — this is the real hemoptysis ; and (2) pneumorrhagia, 
in which the hemorrhage takes place into the air-cells and lung tissue. 
This is known also as pulmonary apoplexy. There are several 
varieties of hemoptysis : (a) in young healthy persons in whom it 
may occur without warning, like a nose-bleed, and after a day or two 
disappear and leave no traces. In many cases of spitting of blood, 
I have found it to be caused by erosions or varicoses at the bifurca- 
tion of the bronchi, (b) From pulmonary tuberculosis. It occurs 
either early in the disease before there are any suspicious physical 
signs, or after the appearance of decided lesions. The hemorrhage 
is bronchial, and comes from a limited focus of the disease. "When 
the lesion is more advanced it results from the erosion of an artery, 
(c) It may come from cancer, gangrene, or abscess, (d) It is met 
with in many heart affections, especially in mitral lesions, (e) In 
ulcerative affections of the larynx, trachea, or bronchi, (f) An 
aneurism may break into the air-passages, (g) It may be vicarious, 
appearing instead of the menses, in youth or at the change of life. 
Periodical hemoptysis has occurred after double ovariotomy, ending 
fatally, when no lesion was found to account for it. (Osier). Fin- 
ally, hemoptysis may occur as a symptom of gout, in malignant 
fevers, in purpura, and from foreign bodies inhaled. Hemoptysis 
generally occurs suddenly. It is sometimes preceded by a salty 
taste in the mouth, and cough. The amount may be small, only an 
ounce or two brought up, or the quantity may be great, flooding the 
bronchi, and pouring from the mouth. One evening a large robust 
workman, who had never been ill, rushed into my office spitting 



DISEASES OF THE RESPIRATORY SYSTEM. 331 

large mouthfuls of blood and struggling for breath. Within ten 
minutes he ejected two quarts of blood and died suddenly ; the whole 
duration of the hemorrhage did not last over an hour. A post-mortem 
was refused. It is often difficult in profuse hemorrhage to decide 
whether the blood is from the stomach, or is coughed up, for some- 
times the blood from the lungs is swallowed in such quantities as to 
provoke vomiting. (See differential diagnosis under Hematemesis.) 
After the hemorrhage has ceased the sputum will be tinged with 
blood. 

The result of this hemorrhage may be gangrene, or a cavity, or 
it may be absorbed, and a puckered, fibroid patch remain. 

Treatment of Hemoptysis. — There has been of late a radical 
change in the dominant school in their treatment of pulmonary 
hemorrhage. All astringents are abandoned. Ergot, once con- 
sidered specific, is rarely used. This change has been brought about 
by the experiments of Dr. Bradford and Dr. James Andrews of 
England. They demonstrated that while the pulmonary circulation 
in man is under vaso-motor control, our knowledge of the mutual 
relations of pressure in the aorta and in the pulmonary artery under 
varying conditions is very imperfect. Experiments with drugs on 
animals seem to show that there may be an influence on systemic 
blood-pressure, without any on the pulmonary, and the pressure in 
the one may rise while it falls in the other, or it may rise and fall 
in both together. Ergot was found to cause a distinct rise in the 
pulmonary blood-pressure, while aconite produces a definite fall, not 
only in the pulmonary but in the carotid arteries. Strophanthus 
caused a rise in the carotid, and a slight fall in the pulmonary 
arteries. Digitalis caused a great rise of blood-pressure in both. 
Strychnine produced the same results. 

Chloroform caused both pressures to fall. Ether caused both to 
rise. If these experiments (made on animals) indicate that the 
same conditions would occur in men, then aconite is the only drug 
in the above list that should be used in hemoptysis, according to the 
doctrines of the regular school. 

I am not sure that aconite can cause hemoptysis, a real bron- 
chorrhagia. Its primary action in lowering blood-pressure every- 
where is certainly to antagonize such an occurrence, I have never 
been able to find in the provings of aconite that it has caused hem- 



332 THE PRACTICE OF MEDICINE. 

orrhage from the lungs. A study of the writings of Richard Hughes 
and T. F. Allen convinces me that they are of the same belief. If 
it has caused " cough with scanty expectoration of frothy, bloody 
sputum," as some of the Austrian pro vers assert, an examination of 
their records show they were not healthy men, in fact they had been 
troubled with the same symptom previous to the provings. The sec- 
ondary effect of aconite is capillary blood stasis, which may result 
in passive hyperemia of the bronchial mucosa, which Osier says may 
result in hemoptysis. Aconite is, however, a potent remedy for pul- 
monary hemorrhage, but only when it is caused by abnormal vas- 
cular excitement. Its primary action is to quiet the beating of an 
excited heart and lessen the blood-pressure in the arteries. In this 
way, and in no other, does it arrest pulmonary hemorrhage. The 
character of the hemorrhage that aconite arrests is characteristic. 
The blood is florid, and if mixed with mucus is in spots, showing 
that at each pulsation it spurted from the arterioles. When it comes 
from an artery, it is in masses that coagulate as soon as it is expec- 
torated. The subjective symptoms are anxiety and fear of death ; 
a sensation of heat and orgasm in the chest, and profuse discharges 
of blood when not coughing. The dose is immaterial so long as it 
lies between a drop of the tincture or the lx or 2x dilution. It 
should be frequently repeated until the pulse softens, and the heart 
is quieted. 

Veratrum viride is indicated for a higher grade of cardiac excite- 
ment, with heavy, full pulse, but the mental demeanor is different 
from that of aconite. The patient seems calm and indifferent. 
The blood flow is in large quantity, and fairly spouts from the 
mouth. 

Dr. Goss, in his " Practice," recommends alternating aconite in 
small doses with ergot in large doses (fifteen to twenty drops) every 
one or two hours. This is an absurd procedure, as the two drugs 
are antagonistic. He praises lycopus virginius very highly. He says, 
" This plant possesses sedative powers by which it controls the cap- 
illary circulation, and lessens the calibre of these minute vessels. 
It is much safer than digitalis. So positive is its action in hemop- 
tysis that I seldom have to use any other remedy to check ordinary 
cases." I can bear witness to the controlling action of lycopus in 
hemoptysis, but it is not useful when there is high temperature. If 



DISEASES OF THE RESPIRATORY SYSTEM. 333 

there is no fever, and the pulse is quick and irritable, especially in 
tubercular subjects, it is very serviceable. It is also useful when 
mental excitement or physical exertion is the cause of the hemor- 
rhage. The dose is fifteen to thirty drops of the tincture every half 
hour. 

Cactus stands high in the treatment of pulmonary hemorrhage 
without fever, when there is great cardiac excitement with violent 
spasmodic systole. The chest is very much oppressed, with a sensa- 
tion as if the heart were constricted by an iron band. The blood is 
arterial and in large quantities ; lying down aggravates both cough 
and hemorrhage. The dose is ten drops of the mother tincture or lx. 

The use of ergot in hemoptysis need not be abandoned by our 
school. It is homeopathic to active arterial hemorrhage because it 
primarily raises the blood-pressure in the lungs. Therefore it should 
in this condition be prescribed in the 2x or 3x dilution of Squibb' s 
fluid extract or "Normal tincture." The dilution should be made 
with distilled water and used hypodermatically, injecting ten to 
thirty drops every hour. It is also secondarily homeopathic, for its 
secondary effect is to cause passive hyperaemia of the pulmonary arter- 
ies and veins. 

Lilienthal gives the correct indications for it in this condition, 
viz., " Passive pulmonary hemorrhage, mostly venous, but may be 
arterial ; usually preceded by a sensation of pressure upon the chest, 
with weak and small pulse. The patient wants to lie with the head 
low, and wants the window open." Dose, five to ten drops of the 
preparations above mentioned. 

In addition to ergot, the only remedies for venous hemorrhages 
are hamamelis, carduous, collinsonia, and aloe. 

The last three are indicated when the portal circulation is engorged, 
and the patient has piles, or hepatic disease. 

The other remedies for arterial hemoptysis are ferrum, acalypha, 
ipecac, millefoil, sanguinaria, senecio, erigeron, ruta, and turpentine. 
The action of sanguinaria, senecio, erigeron, and turpentine is sim- 
ilar to ergot, and can be used in passive as well as active hemor- 
rhage. 

Sanguinaria and senecio are useful in vicarious hemoptysis from 
suppressed or absent menses, and when occurring during tuberculosis. 

Arnica is useful, but not always, because of traumatic causes. 



334 THE PRACTICE OF MEDICINE. 

It is indicated when the symptoms, the dark, coagulated blood, with 
stitching in the chest, with a bruised feeling, etc., call for it. 

Bryonia is an analogue of arnica with very similar symptoms. 

I never found cinchona of any value except in the weakness from 
loss of blood, but quinine is homeopathic to hemoptysis, and I have 
known it to excite hemorrhage in many instances when given in 
large doses. It is specific when the hemorrhage comes on in par- 
oxysms of regular recurrence, malarial or not. The late Dr. H. A. 
Johnson, of this city, prescribed it (in consultation) for a patient 
of mine, who had attacks of hemoptysis every night at midnight. 
Ten grains every six hours arrested it, and on its recurrence several 
weeks later, had the same effect. 

Ustilago and viscum album can be used instead of ergot, as their 
action is quite similar. 

Antipyrin, five to fifteen grains, has arrested profuse hemorrhage 
from the lungs. 

Hydrastis and its alkaloids have lately attained a very high rank 
as hemostatics. Dr. Schaots was the first to use it in uterine 
hemorrhages, and to strangle the circulation in uterine fibroids. 
They have been found superior to ergot, causing no unpleasant symp- 
toms, but improving the general health of the patients. Another 
German authority says that for several years he has been using no 
other remedies than hydrastis and hamamelis in hemoptysis, and 
has found them singularly successful. He does not confine the use 
of the latter to venous hemorrhages. 

I have for several years doubted the propriety of giving hama- 
melis for venous hemorrhages alone. Can a drug contract the coats 
of veins without acting similarly on the arteries ? In two cases of 
paroxysmal hemoptysis, I found that hydrastis prevented the attack 
if given continuously in doses of ten to thirty drops of the tincture 
three times a day. The white alkaloid, muriate of hydrastine, in 
doses of one-eighth to one-half of a grain, has been used successfully. 
Another preparation, the sulphate of hydrastinine, has been found 
more prompt in its action than hydrastis. It is prescribed in one- 
eighth to one grain doses three times a day. 

There is a form of hemoptysis occurring in old people, which has 
been found to depend on a hemorrhage in and around emphysema- 
tous patches. Dr. Andrew says that all the ordinary medicines fail, 



DISEASES OF THE RESPIRATORY SYSTEM. 335 

but that if a small dose of mercurius dulcis be given at night, fol- 
lowed by a saline laxative in the morning, it will benefit a majority 
of cases. 

One of the popular remedies in domestic practice for spitting of 
blood is common salt. A teaspoonful or less is placed on the tongue 
and allowed to dissolve slowly. It often arrests the hemorrhage, but 
its manner of action has never been satisfactorily explained. When 
the ice compress " fad " was the fashion in Germany, it was advised 
to apply ice bags and the ice-water coil to the chest in hemoptysis. 
It is a senseless procedure, because it contracts the capillaries of 
the chest wall, and increases the amount of blood in the lungs. More 
logical is the suggestion by an eminent German authority, to apply 
cold air to the bronchial surfaces by inhaling from a tube, air made 
ice cold by passing through a freezing mixture. He claims that by 
this method he has in several cases arrested the hemorrhage. 

It is sometimes advised that the patient, as soon as he is attacked, 
shall lie down with the head low, and rest as absolutely quiet as pos- 
sible. I do not believe the recumbent position with the head low is 
rational. In this position the heart sends more blood to the lungs, 
and with greater force. I believe the head and upper part of the 
body should be nearly upright. I have known the act of lying down 
to bring back the hemorrhage. I allow my patients to sit in a chair 
or walk slowly around the room, carefully avoiding any sudden effort. 

The diet should be of liquid, unstimulating food, taken cold ; 
milk, buttermilk, ices and ice creams, are sufficient during the attack^ 
and until all traces of blood disappear from the expectoration. It 
was once taught that the act of coughing was beneficial as it brought 
up the blood, which otherwise might clot in the bronchi. But cough- 
ing certainly increases the flow of blood from bleeding vessels and 
increases the lesions therein. Never allow patients to cough if it be 
possible to prevent it. All the effort necessary to get up the blood 
is a " hemming " effort. Old-school works all advise morphine, and 
it is better to give it than allow a hard, shaking cough. 

Codeine will arrest a cough and the patient will escape the nausea 
and prostration of morphine. Give one-tenth grain every half-hour 
until it gives relief. 

Syrup or tincture of lactucarium acts well in soothing the cough ; 
sometimes drosera and hyoscyamus act very favorably. 



336 THE PRACTICE OF MEDICINE. 

BRONCHO-PNEUMONIA (Capillary Bronchitis.) 

Definition. — This disease is essentially an inflammation of the 
terminal bronchus and the air vesicle which make up a pulmonary 
lobule. It is also known as lobular, in contradistinction to lobar 
pneumonia. 

The term catarrhal is less applicable. As a rule it is an affec- 
tion (according to Osier) secondary (1) to the infectious fevers, 
whooping cough, measles, and less frequently small-pox, erysipelas, 
and typhoid fever. In children it forms the most serious complica- 
tion of these diseases, and in reality causes more deaths than are due 
directly to the fevers. In large cities it ranks next in fatality to 
infantile diarrhoea. In old people it is an extremely common affec- 
t-ion, following debilitating causes of any sort, and supervening in 
the course of chronic Bright's disease and various acute and chronic 
maladies. 

(2) Whenever the sensitiveness of the larynx is benumbed as in 
the coma of apoplexy or uremia minute particles of food and drink 
are allowed to pass the rim of the glottis, and reaching finally the 
smaller tubes, excite an intense inflammation similar to the vagus 
pneumonia which follows section of the pneumogastric in the dog. 

(3) The most common and fatal form of broncho-pneumonia is 
that excited by the tubercle bacilli." 

In a majority of cases pneumonia of infants under five years of 
age assumes this form. Rickets and diarrhoea are predisposing 
causes. It prevails more extensively among the poorer classes 
because they are more exposed and cannot have the needful care dur- 
ing eruptive fevers. 

Broncho-pneumonia may terminate (1) In resolution, which, 
when it once begins, goes on more rapidly then in fibrous pneumonia. 
If it attacks the apices of the lungs in a child and persists for three 
or more weeks it is often tuberculous. When we suppose resolution 
is delayed, caseation has taken place. (2) In the aspiration-forms 
suppuration or gangrene often occurs. (3) Fibroid changes some- 
times occur ; then it is called chronic broncho-pneumonia. 

Osier says, " Much confusion has arisen from the description of 
capillary bronchitis as a separate affection, whereas it is only a part, 
though a primary and important one, of broncho-pneumonia." 



DISEASES OF THE RESPIRATORY SYSTEM. 337 

Eustace Smith (" Diseases of Children ") takes the same view, 
but he teaches that it is generally catarrhal in its origin, and not due 
entirely to the contagious fevers. Osier gives the symptoms as fol- 
lows : " If during convalescence from measles or whooping cough, a 
child has an accession of fever, with cough, rapid pulse, and rapid 
breathing ; and if, on auscultation, fine rales are heard at the bases, 
or widely spread throughout the lungs, even though neither consol- 
idation or blowing breathing can be detected, the diagnosis of bron- 
cho-pneumonia may safely be made. I have never seen in a fatal 
case after diphtheria or measles a capillary bronchitis as the sole 
lesion." 

The dyspnoea is constant and progressive, and soon signs of defi- 
cient aeration of blood are noted. The face becomes a little suffused, 
and the finger-tips bluish. The child has an anxious expression, 
and gradually enters upon the most distressing stage of asphyxia. 
At first the urgency of the symptom is marked, but soon the benumb- 
ing influence of the carbon di-oxide on the nerve centres is seen and 
the child no longer makes strenuous efforts to breathe ; the cough 
subsides, and with a gradual increase in lividity and a drowsy rest- 
lessness. The right ventricle becomes more and more distended, the 
bronchial rales become more liquid as the tubes fill with mucus, and 
death occurs from heart paralysis. The older writers called this 
" suffocative catarrh." 

Eustace Smith gives a graphic description in his article on bron- 
chitis. He says, " When the inflammation penetrates the smaller 
tubes (capillary bronchitis) the symptoms become alarming. The 
features look pinched, and the expression is one of extreme distress. 
The face is pale with much lividity about the nose and mouth. The 
child is restless. His dyspnoea is great and his respiratory move- 
ments are labored as well as hurried, but if the disease is uncompli- 
cated with collapse or lobular pneumonia there is little disturbance 
of the normal proportion between the pulse and respiration. Often 
the child is subject to suffocative spasms if laid down, and has to be 
supported partially upright in the nurse's arms, or raised in his cot 
by pillows ; at each inspiration considerable recession is noticed of 
the soft parts of the chest, and if the ribs are yielding from rickets, 
the retraction of the bones of the chest may be extreme. The tem- 
perature at first is raised to 101° or 102°, but when aeration of the 



338 THE PRACTICE OF MEDICINE. 

blood is greatly interfered with the mercury usually sinks to 99°. The 
pulse rises to 140 or 150 or higher. The cough is hacking and hoarse, 
and occurs in stifling paroxysms. The skin is moist and sweat 
stands in beads on the forehead. Appetite is lost, and the child is 
thirsty, but on account of dyspnoea he cannot drink or draw fluid 
from the bottle. Vomiting sometimes follows coughing, when much 
whitish and yellow phlegm is thrown up. He rarely speaks or cries, 
as he has no breath to spare." I once attended several notable cases 
of capillary bronchitis, which did not follow any eruptive fever. 
They began suddenly without any apparent cause. The dyspnoea 
was great, efforts to cough constant, but the one peculiarity about 
them was, that through the nose and mouth there constantly welled 
up a snowy froth, so light that it floated away on the air. The 
weather was below zero. No medicine seemed to have the slightest 
effect, and death occurred on the fifth day. I have never before or 
since seen or heard of similar cases. 

Percussion in capillary bronchitis discovers no dullness. Aus- 
cultation reveals fine subcreptitant rales over both lungs. The breath- 
ing is nowhere bronchial or blowing, and the resonance of the voice 
is unaltered if the disease is uncomplicated. 

If the case terminates favorably the eyes grow brighter and livid- 
ity begins to clear ; the cough is looser and less paroxysmal ; the pulse 
slackens, the breathing is less labored, and the child takes more 
notice. 

Osier asserts that " it is a superfluous refinement to make a diag- 
nosis between capillary bronchitis and catarrhal pneumonia, for the 
two conditions are part and parcel of the same disease." This state- 
ment should be borne in mind when consultation takes place. I have 
known much dissatisfaction among parents and ill feeling between 
physicians, because of the determination of one to call the disease 
capillary bronchitis, the other catarrhal pneumonia. 

The prognosis is bad in feeble and ill-nourished children and 
feeble old men, but recovery may take place in apparently very bad 
cases. Remember the old maxim : " Never despair of a sick child." 
The death-rate in children is estimated at from thirty to fifty per 
cent. 

Preventive measures may help much to avoid an attack of capil- 
lary bronchitis in children after measles and similar diseases. The 



DISEASES OF THE RESPIRATORY SYSTEM. 339 

temperature of the room should not vary more than two degrees day 
and night. The child should be kept covered all the time with the 
same amount of clothing, unless the temperature of the room acci- 
dentally falls. If nurses are not watchful children will kick off the 
bed clothes and lie naked or with exposed limbs, but the use of flan- 
nel "combination " suits of underclothing is a great aid to prevent 
this exposure. 

Treatment. — On the appearance of symptoms threatening bron- 
chitis in a young child, particularly after eruptive fevers, the uni- 
form temperature of the room should be kept between 68° and 72°. 
Some authors, especially English, say between 60° and 63°. This 
temperature may be appropriate for English and Continental chil- 
dren, but not for the inhabitant of the United States. The truth of 
this statement I have had frequent occasion to substantiate, for I have 
seen children improve as soon as the temperature of the room was 
raised from 60° to 70°. 

If the symptoms indicate actual broncho-pneumonia, order a flax- 
seed poultice (not too thick, for the weight of a poultice often 
oppresses the patient), in which is stirred oil or glycerine, applied 
to the chest. After a few days this can give place to a compress of 
raw cotton. When the poultice is removed the chest should be 
rubbed with camphorated oil before the cotton is applied. The poul- 
tice or cotton jacket should go all around the body — the back should 
be protected as well as the anterior of the thorax. 

The diet should consist of milk, clear broths, and egg albumen. 
The milk should be well shaken, or mixed with barley-water. 

The two remedies during the acute inflammatory stage are aco- 
nite or veratrum viride, but neither should be given many hours, and 
their effects should be closely watched. A high temperature, a small 
hard pulse, great anxiety and restlessness, with crying and moaning, 
dyspnoea, hot skin (not always dry), thirst, and suffering on being 
touched or moved, dry cough, or with scanty glairy sputum, spotted 
with blood, indicate aconite one-tenth or one-hundredth of a drop 
every hour. If the temperature is very high, the skin hot, red, and 
dry, the eyes suffused and bloodshot, the head hot and rolling, a 
stupor instead of restlessness, a cough with blood-streaked expector- 
ation, a pulse full, hard, bounding, and rapid, then veratrum viride 
is the remedy. The dose is the same as recommended for aconite. 



340 THE PRACTICE OF MEDICINE. 

As soon as the pulse becomes slower and softer, and the tempera- 
ture drops a few degrees, these medicines should be stopped, and bel- 
ladonna, bryonia, or scilla substituted. The indications for bella- 
donna are decided cerebral symptoms, due to the inflammation being 
seated in the upper portion of the lungs. It is known that when 
this occurs the symptoms may resemble meningitis more than pneu- 
monia. The rolling of the head, delirium, startings, and convul- 
sions, also the throbbing temporal arteries and dilated pupils, call for 
belladonna. 

Bryonia may be indicated in some cases of broncho-pneumonia, 
but I rarely use it in that disease. The symptoms " pain on move- 
ment, on being touched, on coughing, and sharp pains in the side," 
which children old enough will complain of, do not really indicate 
bryonia, unless we find on auscultation signs of pleuro-pneumonia. 

Squills (scilla), rarely mentioned in our text-books, is the rem- 
edy above all others after aconite and belladonna. Pathologically 
it corresponds in every particular to the symptoms and morbid anat- 
omy of broncho-pneumonia. It causes acute inflammatory capillary 
bronchitis, which runs the same course, and ends with the same car- 
diac failure as the natural disease. All the symptoms closely cor- 
respond, and I have always been surprised that it was not used in 
the homeopathic school. Perhaps it is the abuse of it in regular and 
domestic practice that has led us to avoid it. This has been a great 
mistake, as we might save, with proper use of it, as many as are 
destroyed by its abuse. Squills causes a rise of the normal temper- 
ature, hot dry skin, incessant dry or spasmodic cough, which appears 
to pain the child greatly. Aversion to movement or to be laid down, 
great dyspnoea, and struggling for breath, owing to the clogging up 
of the bronchioles. The sputum is frothy, glairy, red, and difficult 
to detach. The pulse is small, hard, and quick. During this first 
stage, give tincture of squills in the 2x or Ix dilution, Olyq to ten 
drops in a solution of chloroform, 1 to 1000, every hour or two. If 
this disease passes into a later stage, when the right side of the heart 
becomes distended and the heart's force declines, threatening failure, 
give larger doses, one to three drops of the tincture in glycerine and 
water, a dose every two hours. 

Squills causes nearly all the cardiac symptoms met with in cap- 
illary bronchitis ; first, cardiac excitement ending in tetanic contrac- 



DISEASES OF THE RESPIRATORY SYSTEM. 341 

tion in systole. It is this power which makes it so useful in that 
disease. It is as much the heart failure as any other condition that 
causes death. If we can sustain the heart, the child has many more 
chances of recovery. The reason I advise large doses when heart 
failure impends is that it is a secondary effect of squill, which causes 
cardiac paralysis in diastole. Given for this indication it acts as a car- 
diac tonic, and will remove the small, quick, irregular pulse, the cold, 
livid face and extremities, and suffocative attacks from large accu- 
mulation of mucus in the bronchi. It is in this stage that the old 
school find it so useful when they do not give it in toxic doses. But 
generally the dose is excessive, and tends still more to engorge the 
right heart, and to weaken it. Nearly all the authorities caution 
against its use during the inflammatory stage, and urge that in the 
second stage its effects shall not be pushed to vomiting, for the vom- 
iting of squill is like the vomiting of digitalis, it means heart fail- 
ure. If the symptoms of this stage do not give way to squills, and 
deficient aeration from carbon di-oxide poisoning continues, add to 
the squill glonoine, to open the arteries and arterial side of the 
heart so as to allow the venous blood to be passed onward and 
become aerated. It is infinitely superior to ammonia or alcohol. 
A child will bear the one-hundredth grain every two hours with ben- 
efit. When danger is imminent, try inhalation of oxygen gas, which 
is said to have saved some desperate cases. 

Tartar emetic is homeopathic to all the stages of capillary bron- 
chitis after the acute inflammation, but is not equal to squills, yet 
many children and old people have been saved by it (and prob- 
ably as many sacrificed to its abuse) . When the secretion is scanty, 
bloody, and tenacious, with great dyspnoea and oppression on the 
chest, with short, superficial breathing, give the 3x, a grain every 
hour ; but when at a later stage the bronchi are filling up with the 
profuse secretion and threaten suffocation, when loud coarse rattling 
rales are heard at a distance, and the lips and fingers are livid, 
though the heart seems active and regular, give a grain of the 2x 
every hour until there is decided improvement. 

Sanguinaria and chelidonium are both useful when the right lung 
is affected and the liver is congested, causing yellow bilious diarrhoea. 
Their bronchial symptoms resemble those of tartar emetic. Iodine 
and phosphorus are not fully indicated in uncomplicated broncho- 



342 THE PRACTICE OF MEDICINE. 

pneumonia. They act better when there is lobular pneumonia con- 
nected with the former. 

Grindelia has in some instances been of value in cases where the 
dyspnoea is asthmatic in character, and the child starts from a 
momentary sleep, or just as he is falling asleep, with looks of fear 
and a struggle for breath. There are loud rales, and a weak irregu- 
lar action of the heart. The dose is two drops of the tincture every 
hour, in glycerine and water. 

Digitalis should not be used, as it contracts the arterioles and 
increases the distention of the right heart. Cactus is more appro- 
priate as it does not contract the arterioles and capillaries, but 
increases the force of the heart by its direct action on that muscle 
and its motor nerves arising from the spinal cord. 

If children could define their symptoms in the stage of engorge- 
ment of the right heart, I believe they would give the " iron band " 
symptom of cactus. It acts like squills, without its effect on the cap- 
illaries of the bronchi. The dose of cactus to a child need not be 
smaller than one drop of the tincture, and five is not too much in the 
stage of impending paralysis. In old people thirty to forty drops 
may be given safely. If there is much arterial tension it is best to 
alternate it with glonoine. 



PNEUMONIA. 

Definition, — Recent researches into the nature of pneumonia 
seem to prove that it is an infectious disease, characterized by 
inflammation of the lungs, with constitutional disturbances of vary- 
ing intensity, and a fever terminating abruptly by a crisis. An 
organism, the diplococcus-pneumoniae, is invariably found in the dis- 
eased lung. 

Etiology. — Pneumonia is one of the most widespread of acute 
diseases. It attacks all ages, children as well as adults, and it is the 
special enemy of old age. The dwellers in cities, and persons 
exposed to cold, hardships, and insufficient food, are most liable to 
this disease. Contrary to the rule in other infectious diseases, native 
inhabitants are more liable to it than new-comers. Alcohol renders 
its votaries very subject to pneumonia. Persons weakened by dis- 
ease are prone to contract it. An important predisposing cause is a 



DISEASES OF THE RESPIRATORY SYSTEM. 343 

previous attack. No disease recurs with such frequency ; ten or 
more attacks are not uncommon. 

Climate does not appear to have much to do with it. It is rather 
more prevalent in the Southern than in the Northern states. The 
influence of season is most important. Statistics everywhere show 
that more persons are attacked from December to May than in the 
summer or autumn. The month which shows the slightest variation 
of temperature has less cases of pneumonia occur in it. It may 
occur as an epidemic, which fact is considered proof of its infectious 
nature. 

The diplococcus which is supposed to cause this disease generally 
attacks the lungs, but it has been found in the pleura, meninges of 
the brain and cord, and in the endocardium. It has been found in 
the buccal secretions of healthy persons. It is supposed that it only 
invades the lungs when the system has been lowered in tone. Some 
interesting studies have been made by Klemerer on the production 
of immunity and the cure of pneumonia. It was found that animals 
were rendered immune by subcutaneous injection of filtered bouillon 
cultures, or a glycerine extract of the micro-organism. This immun- 
ity rarely lasted more than six months, but was transmitted to the 
offspring born within that period. They found that the serum and 
fluids of the body of an animal rendered immune had the power of 
not only producing immunity in others, but of actually curing the 
disease after infection had been in progress for some time. In dis- 
eased animals who had a temperature of 40 C. (104° F.), the fever 
fell to normal within twenty-four hours after the injection. 

Pathologists recognize three stages in the inflamed lung : engorge- 
ment, red hepatization, and gray hepatization. A full anatomical 
description of these stages is found in all text-books. 

After death the heart is distended with a firm coagulum, which 
can be withdrawn from the vessels in moulds. The distension of 
the right chambers of the heart is particularly marked ; the left 
chambers are rarely distended to the same degree. 

Pericarditis is not infrequent when the left lung is inflamed. 
Endocarditis and meningitis are common. 

Symptoms. — There is a violent chill in the beginning, more 
severe than in any other disease except puerperal peritonitis and con- 
gestive malaria. The fever rises rapidly, and reaches 104° to 105° P. 



344 THE PRACTICE OF MEDICINE. 

The pulse is full and bounding ; respiration very rapid ; there is 
pain in the side of an agonizing character (or but little or no pain, 
as I have observed in several cases), and a short, dry, painful cough, 
which in a few days is attended by a blood-tinged, tenacious expec- 
toration. After the disease is fully developed the patient lies flat in 
bed, often on the affected side ; the face, especially the cheeks, is 
deeply flushed, the breathing is very hurried, the alae dilated with 
each inspiration, the eyes are bright and the expression anxious. 

After persisting from seven to ten days a crisis occurs, and with 
a fall in temperature the patient passes from a condition of extreme 
distress to one of comparative comfort. In cases of delayed resolu- 
tion the fever may persist for some days. The respiration in pneu- 
monia may be very frequent, forty to sixty a minute in adults, and 
eighty in children. 

The dyspnoea is often intense, owing partly to the fever and 
partly to the loss of function in such a considerable area of the lung, 
and to the pain. Often the respiration will fall to nearly normal, 
while the consolidation persists. The inspiration is short and super- 
ficial ; the expiration associated with a short grunt. This last symp- 
tom will often enable us to diagnose pneumonia in children. The 
ratio between the respirations and the pulse may be one to two, or 
even one to three. In no other disease do we see such marked dis- 
turbance in the ratio. 

The cough is at first dry and hard. In drunkards and old per- 
sons there may be no cough. An active spitting of blood may usher 
in the disease. 

The expectoration, at first viscid and blood-stained, becomes 
rusty, more and more as the disease progresses, and is so tenacious 
that it has to be wiped from the lips of the patient, and the half- 
filled spit-cup may be inverted without spilling. Towards the close 
it becomes more liquid and is more easily expelled. In low types 
of the disease the sputum may be fluid and dark brown like prune 
juice. 

These symptoms are so peculiar to pneumonia that any observing 
physician can diagnose the disease without a physical examination. 
Those who desire to consult exact authorities are referred to Dr. H. 
C. Clapp's work on " Diagnosis of Diseases of the Chest." 

The mortality in pneumonia under the ordinary drug or heroic 



DISEASES OF THE RESPIRATORY SYSTEM. 345 

treatment averages about twenty-five per cent. Under the expec- 
tant treatment, which implies the rare use of drugs with good nursing 
and proper diet, it averages about seventeen per cent. The average 
mortality under homeopathic treatment is eight per cent. Not only 
is the death-rate less, but the duration of the disease is modified, 
and the crisis does not appear so often — the fever declining grad- 
ually. The physical signs do not persist as long under homeopathic 
as under the expectant or the heroic treatment. The complications 
are less severe, and sequelae are less frequent. 

Notwithstanding these facts, Dr. Osier says : " Pneumonia is a 
self-limited disease, and runs its course uninfluenced in any way by 
medicine. It can neither be aborted nor cut short by any known 
means at our command. Even under the most unfavorable circum- 
stances it will terminate abruptly and naturally without a dose of med- 
icine having been administered." ("Practice of Medicine.") He 
may be right in asserting that it cannot be aborted or cut short, but that 
it cannot be influenced in any way by medicine is a false assertion, for 
he admits that the mortality under expectant treatment is less than 
under the heroic, i. e., bleeding, calomel, and antipyretics. It is 
false because he ignores the favorable results accruing under homeo- 
pathic treatment. The treatment advised by Osier is anything but 
expectant, and it is no wonder that his average mortality under it is 
as high as twenty per cent. He advises Dover's powder, cupping, 
leeching, blistering, morphine, and even venesection, " in full-blooded 
healthy men with high fever and bounding pulse." His colleagues 
not in hospital practice could teach him that a few doses of vera- 
trum viride would be better in such cases than to drain away the 
vital fluid. 

Osier advises against the new antipyretics — quinine, antipyrine, 
antifebrin, and phenacetine, and implies that they do more harm 
than good. He says : " Fever alone is not, I think, hurtful, but pro- 
longed pyrexia is undoubtedly dangerous and should be combatted." 
He and many American physicians are influenced by the baneful 
practice of Germans like Niemeyer, who advise " ice bags to the 
affected side," a practice which I believe to be dangerous. If the 
temperature rises above 104°, sponging with water at a temperature 
of 80° is all the cold that can be safely applied. 

The diet is an important part of the treatment. It should be 



346 THE PRACTICE OF MEDICINE. 

light, and made up of articles which will digest easily, and not cause 
flatulence. If starchy gruels are given, diastase, papoid, or pan- 
creatine should be added. Milk, wine whey, broths, meat juices, 
and eggs, should constitute the main articles of food. If starch and 
milk cause flatulence they should be discarded. Gruels made of 
baked flour rarely cause flatulence, nor does buttermilk as a rule. 
The use of Vichy or some mild alkaline water as a beverage is both 
grateful and beneficial. 

The chest need not be "bundled up " with poultices or flannels. 
A compress of raw cotton kept over the chest, and the surface of the 
chest well oiled with vaseline or any simple unguent, is all the pro- 
tection necessary. 

In country practice, hen's oil, goose oil, and even skunk's and 
rattlesnake's oil are held in high esteem by the people. There is 
no objection to their use if they are not spoiled or rancid. It is 
possible that the oils from the smaller animals are more readily 
absorbed. 

Medicinal Treatment. — At the onset of the disease, when the 
arterial excitement is great, the pulse hard and bounding, the oppres- 
sion of the chest and dyspnoea severe, I am sure that I have seen 
veratrum viride in small doses, one or two drops every half-hour, 
modify the intensity of the attack. I believe I have seen it abort 
or cut short an attack, and although it may have been congestion of 
the lungs with high fever, I cannot relinquish my belief. Perhaps 
all pneumonias are not caused by the diplococcus ; there may be 
idiopathic cases not due to micro-organisms. 

I believe, also, that I have seen typical cases, during the first 
two days, cut short by the action of aconite. The pain, anxiety, 
agony of dyspnoea, and distressing respiration have subsided under 
its use, and a milder type of the disease followed, so mild that had 
not physical examination showed consolidation, pneumonia would 
not be believed to be present. 

I have no fear of these medicines causing weakness of the heart, if 
used only during the high temperature ; nor have I any fear of phe- 
nacetine when used for pain, in doses of two, three, or five grains 
every two or four hours. In doses of twenty to thirty grains it 
may cause serious cardiac weakness, but such doses are not to be 
thought of. 



DISEASES OF THE RESPIRATORY SYSTEM. 347 

Bryonia, squills, and asclepias tuberosa are indicated by the 
symptoms noted under pleurisy, and one of them can be alternated 
with aconite or veratrum. They are useful in any stage so long as 
their peculiar symptoms are present. Phosphorus and sanguinaria 
are the special remedies during the stages of red and gray hepatiza- 
tion. If there is any difference in their indications, phosphorus is 
better when the left lung is affected, sanguinaria when it is the right 
lung. Chelidonium, the half-brother of sanguinaria, may replace 
the latter when there is evident hepatic derangement. 

There is a so-called "bilious pneumonia" in which the liver 
becomes implicated by extension of the inflammation or the migra- 
tions of the diplococcus to that organ. If jaundice with pale stools 
and bilious urine occurs, give small doses of euonymin or mercu- 
rius. If a yellow bilious diarrhoea sets in instead of jaundice, give 
chelidonium, carduus, or tartar emetic. 

The fever of phosphorus and sanguinaria is remittent and appears 
about 2 P. M., with circumscribed redness of the cheeks, aggravation 
of the cough, and dyspnoea. It becomes lighter towards midnight, 
and in the early morning the patient is quite comfortable. 

Phosphorus is also indicated when the disease takes a severe form 
and the lungs are so extensively consolidated that the right heart 
becomes engorged. The extremities are cold and dusky, the lips and 
nose cyanotic, the pulse thready and quick. In this condition it must 
be given liberally, ten to twenty drops of the tincture in water (kept 
in a dark bottle), a spoonful every half -hour. For similar symptoms 
iodide of arsenic or turpentine are sometimes indicated. 

Tartar emetic is useful for symptoms not so grave as those of 
phosphorus, but when the tenacious mucus so fills the bronchi that 
it impedes respiration, and loud rales can be heard at a distance, 
then a grain of the 2x repeated every half-hour gives great relief 
and prevents a recurrence of the same condition. 

Iodine is highly recommended by Kafka in all stages of pneu- 
monia, but it appears to me upon insufficient grounds. It is doubt- 
less useful in croupous pneumonia because it is indicated in all 
croupous processes, but it cannot take the place of aconite, veratrum 
viride, or bryonia in the first stages ; or phosphorus and sanguin- 
aria in the second and third. When an inflammation of the bronchi 
has extended to the parenchyma, iodine may be useful so long as 



348 THE PRACTICE OF MEDICINE. 

the bronchitis lasts. Those physicians who report having treated 
pneumonia successfully with iodine should remember that the dis- 
ease will run its course to a favorable termination without medicine. 
It cannot be considered specific until its use shall reduce the death- 
rate below six per cent. 

Ipecac cannot be considered a true pneumonic medicament, neither 
can bichromate of potassium, carbonate of potassium, carbo vege- 
tabalis, or hepar sulphur. 

Sulphur is useful when the stage of resolution is tardy and delay- 
ing. It arouses the torpid energies of the system. 

Lycopodium corresponds to a similar condition when the inflam- 
mation is inclined to be chronic and of a low type, with hectic, and 
slow suppuration. The " fan-like motion of the alse nasi " is no more 
an indication for its use than for any other medicine, for that symp- 
tom is present in all severe cases, and always indicates a limited area 
of pervious lung tissue. 

Quebracho, while not having any relation to the inflammation 
itself, is a precious remedy for the very distressing dyspnoea. It acts 
through the pneumo-gastric, and restores its power when it becomes 
paretic. It improves the respiratory efforts, and indirectly the car- 
diac paresis. The dose is ten to fifteen drops of the tincture, or the 
lx or 2x trituration of its alkaloid aspidospermine in one or two 
grain doses every two hours. 

Grindelia robusta is a medicine I value very highly when with 
the dyspnoea there are signs of impending heart failure. The symp- 
tom — "he fears to go to sleep because he is afraid he will stop 
breathing " — and the " waking with struggles for breath," all point 
to paresis of the cardio-motor nerves. In doses of ten or fifteen 
drops every two hours it gives great relief in this condition, and 
rivals strychnine, so much used for those symptoms. 

Osier says : " Of medicinal agents strychnine is one of the most 
valuable, and has come into favor as a useful cardiac tonic. It may 
be given in doses of one-thirtieth to one-twentieth of a grain. I 
have learned to value it much more than digitalis, which I consider 
an unsafe medicine in most cases of pneumonia when the right heart 
is distended.''' I am aware that the use of digitalis in massive doses, 
from the beginning, is highly lauded by some writers, but this is not 
sanctioned by the best authorities. The only cases where I would 



DISEASES OF THE RESPIRATORY SYSTEM. 349 

advise it is in alcoholics, when a condition like that of delirium 
tremens appears, and the left ventricle is dilated, with a loss of con- 
tractile power, or when pneumonia occurs in patients who have 
already a weak, dilated heart ; cactus or strophanthus are generally 
safer and more useful. (Consult the chapter on " The Heart in 
Pneumonia.") 

GANGRENE OF THE LUNG. 

This is not a disease of itself, but occurs when necrosed areas 
undergo putrefaction. It is a consequence of lobar pneumonia, par- 
ticularly in debilitated or diabetic patients. It is prone to follow 
aspiration-pneumonia, and puncture of the lungs by weapons or 
splinters, since the foreign particle carried in rapidly undergoes 
putrefactive changes. It may be caused by cancer of the oesopha- 
gus breaking into the lung. Gangrene may follow embolism of the 
pulmonary artery. It may occur in conditions of debility during 
convalescence from protracted fever, without any assignable cause. 

The sputum is very characteristic ; in the two cases under my 
care the expectoration was so foetid that no nurse " could be hired to 
remain long with the patients. 

Osier gives an accurate description of the sputum. " If expecto- 
rated into a conical glass, it separates into three layers : a greenish 
brown heavy sediment ; an intervening thin liquid, which sometimes 
has a greenish or brownish tint ; and on top, a thick, frothy layer. 
Spread out on a glass plate the shreddy fragments of lung tissue can 
be rapidly picked out. Microscopically elastic fibres are found in 
abundance with granular matter, pigment grains, fatty crystals, and 
bacteria." Post-mortem, localized gangrene has been found when 
it was not suspected during life, showing that unless free communi- 
cation exists between the cavities and the bronchi, no foetor will be 
observed. 

It is difficult to detect the location of the gangrene-area unless it 
be large. Death ensues from hemorrhage, septicaemia, or the patient 
sinks from exhaustion. 

Treatment. — This is very unsatisfactory. If the gangrene-area 
can be located and the patient is not too weak, an attempt should be 
made to treat it surgically. Successful cases have been reported. 
When opened into, the cavity should be treated with iodoform, mer- 



350 THE PRACTICE OF MEDICINE. 

euric chloride, or thymol. Deep inhalation of antiseptic substances 
should be tried; the best are thymol, myrtol, creosote, eucalyptol, 
and terebene. These same medicines should be given internally in 
the hope that their volatile principle may be carried by the circula- 
tion through the lungs and come in contact with the gangrenous area. 
Medicines like arsenic, carbo vegetabalis, ergot, or silica are 
useless. 

EMPHYSEMA. 

A practical division of emphysema may be made into compensa- 
tory, hypertrophic, and atropic. (Osier.) 

It is said to be compensatory when a region of the lung does not 
expand fully in inspiration, and another portion of the lung expands 
enough to compensate, or occupy the space. At first the distension 
of the air vesicles is a simple physiological process, and the alve- 
olar walls are stretched but not atropied. Ultimately, however, they 
waste, and the contiguous air-cells fuse, producing true emphysema. 

Hypertrophic or idiopathic emphysema is a well-marked clinical 
affection, characterized by enlargement of the lungs, due to disten- 
tion of the air-cells and atropy of their walls ; and clinically by 
imperfect aeration of the blood, and marked dyspnoea. Osier defines 
it as " the result of persistently high intra-alveolar tension, acting 
upon a congenitally weak lung tissue." He discards the mechanical 
views of its origin, as it would be more common if that alone were 
the cause. He believes there must first be some nutritive change in 
the air-cells, and a hereditary tendency, or the mechanical tension 
would not cause it. It is very common in children. I can imagine 
that in some children it might be caused by crying spells in which 
they sometimes inspire very deeply and "hold their breath for a 
long time." Violent coughing and all straining efforts in which the 
glottis is closed and the chest walls compressed by muscular efforts, 
throw great strain upon the apices and anterior margins in which 
we find the emphysema most advanced. It is caused by bronchitis, 
or the violent coughing attending it ; by whooping cough, asthma, 
playing on wind instruments, glass-blowing, and violent lifting efforts. 

The thorax assumes a peculiar bowl-shaped appearance, and the 
costal cartilages are calcified. The large bronchi are roughened and 
thickened from chronic bronchitis, and the smaller tubes are dilated* 



DISEASES OF THE RESPIRATORY SYSTEM. 351 

Important morbid changes are found in the heart. " The right 
chambers are dilated and hypertrophied ; the tricuspid orifice is 
large, and the valve segments are often thickened at the edges. In 
advanced cases the cardiac hypertrophy is general. The pidmonary 
artery and its branches may be wide, and show marked atheromatous 
changes." (Osier.) 

The disease may be well advanced before marked symptoms are 
developed. Children may appear somewhat short of breath on run- 
ning or climbing stairs, and during extreme exertion become slightly 
livid. These are the first symptoms. If the cardiac compensation 
is complete there will be no special arrest of the circulation in the 
lungs except from violent exertion. 

In well-developed cases there is always dyspnoea, cyanosis, bron- 
chitis, cough, and asthmatic breathing. They are much better in 
summer than in winter. If the air is warm they are very comfort- 
able, if cold and wet they suffer from bronchitis and cough. 

The physical sounds on inspection, palpation, and percussion must 
be familiar to all. If not, consult some work on physical diagnosis. 
One characteristic on auscultation is the prolongation of the expira- 
tion ; the normal ratio is reversed, four to one instead of one to 
four. This has often decided my diagnosis. Death may occur from 
intercurrent pneumonia, dropsy from cardiac failure, or paralysis of 
the heart with extreme cyanosis. 

Treatment. — The treatment laid down for bronchitis and asthma 
may be applied to emphysema. Bronchitis is the great danger to 
these patients, and they should live in a warm equable climate. 
South Florida is the ideal climate for emphysema. Osier says no 
remedy is known that has any influence over the disease itself. 

Lilienthal gives eighteen medicines, but they are for the symp- 
toms that arise from the pathological state. We know of no drug* 
that cures emphysema. 

A. K. Crawford writes (" Arndt's Practice ") that the remedies 
must be chosen " to stop the progress, or restore the damage done 
to the air-cells "; but he also says " it is impossible to base a ther- 
apy on the pathology." The remedies he recommends are merely 
palliatives, and this is probably all that can be done by medicine. 

Osier says : " When patients come into the hospital in a state of 
urgent dyspnoea and lividity, with great engorgement of the veins, if 



352 THE PRACTICE OF MEDICINE. 

they are young and vigorous they should be bled freely." He says 
he has saved the lives of several persons by venesection. In the 
same condition I have found veratrum viride, one to three drops 
every one-half hour, to have the same effect as bleeding. It acts 
much quicker when given hypodermatic ally. 

There are two medicines only which give continuous relief in 
emphysema — coca and quebracho. They seem to possess a power 
of imparting increased power to the portion of the lung left unin- 
jured. I have found that under the influence of teaspoonful doses 
of a good tincture of coca they are enabled to walk much faster 
and go up-stairs with more comfort. Quebracho in doses of ten to 
fifteen drops of the tincture or one grain of the solid extract, or one- 
fiftieth of a grain of aspidospermine will often have a better effect 
than coca. 

Atropic emphysema is really a senile change, and nothing can be 
done except to give the above mentioned remedies, aided by arsen- 
iate of strychnine, to stimulate the decaying vital forces. One of 
the best palliatives in senile emphysema is lobelia. At one time I 
used it alone, and although I got good results from its use I found 
some objections to it. In one case I added sufficient to a bottle of 
wine of coca to give the patient ten drops to each tablespoonful. 
This seemed to act very favorably, and lately I have generally pre- 
scribed lobelia in that manner. 

ABSCESS OF THE LUNGS. 

Suppuration in the lung occurs under the same conditions as those 
enumerated under gangrene. The abscesses vary in size from a 
walnut to an orange. Embolic or infectious abscesses are common 
in cases of pyaemia. They may occur in great numbers ; as a rule 
they are superficial, beneath the pleura. I have seen several cases 
presenting abscess in the right lung. They occur in chronic pul- 
monary tuberculosis. 

The expectoration is very offensive, yet it rarely has the horrible 
fcetor of gangrene or putrid bronchitis. In the pus, fragments of 
lung tissue can be seen. Embolic cases are generally fatal. Ab- 
scesses after pneumonia may recover. 

Treatment. — The same treatment recommended for gangrene 
should be tried. In addition I recommend balsam of Peru in doses 



DISEASES OF THE RESPIRATORY SYSTEM. 353 

of fifteen drops in syrup or chloroform, every four hours. I believe 
I cured two cases with it. Several cases have lately been reported 
in which the cavity has been aspirated, drained, and disinfected. 
Borated calendula would be an excellent injection. I recall two 
cases in which I believe that the contents of an abscess of the liver 
which broke into the lung were expectorated. Both recovered after 
several months. Nature's methods of opening and draining abscesses 
are often curious and surprising, and the results are astonishingly 
good. 

DISEASES OF THE PLEURA. 

ACUTE PLEURISY. 

Anatomically this disease may be divided into (1) dry or adhe- 
sive pleurisy, and (2) pleurisy with effusion. 

(1) Dry, Fibrinous, or Plastic Pleurisy. — " In this the pleu- 
ral membrane is covered by a sheeting of lymph, of variable thick- 
ness, which gives it a turbid granular appearance, or the fibrin may 
exist in thin layers. It occurs (a) as an independent affection fol- 
lowing cold or exposure." This form is not common in perfectly 
healthy persons. The disease sets in with the usual pain in the side 
and slight fever, and the physical signs of pleurisy are indicated by 
the friction sound. After lasting a few days the friction sound dis- 
appears and no exudation occurs. Union may take place between 
the membranes, or a few adhesions form; or (b) pleurisy may 
occur as a secondary process in acute diseases, as in pneumonia ; can- 
cer, abscess, and gangrene may cause plastic pleurisy. This condi- 
tion is a common one in tuberculosis. Pleural pain, stitch in the 
side, and a dry cough with marked friction sounds on auscultation, 
are the initial symptoms in many cases of phthisis, and these sounds 
usually occur at the bases of the lungs. 

(2) Sero-Fibrinous Pleurisy. — In the majority of cases, with 
the fibrin there is a variable amount of fluid exudate. This is known 
as " pleurisy with effusion." Osier and many recent French writers 
conclude that nearly all pleurisies are in their origin tuberculous. 
He says, " I confess that the more carefully I have studied the ques- 
tion the larger does the proportion of primary pleurisies appear to 
be of tubercular origin." 

23 



354 THE PRACTICE OF MEDICINE. 

Morbid Anatomy. — In sero-fibrous pleurisy the serous exudate 
is abundant, and the fibrin found on the pleural surfaces, and scat- 
tered through the fluid in the form of flocculi. In some cases there 
is very little fibrin, in others it forms thick creamy layers. The 
serous fluid is of a citron color, either clear or slightly turbid, but it 
may have a dark brown color. On boiling it will be found rich in 
albumen. Sometimes it coagulates spontaneously. The amount 
varies from a half to four litres (one-half to four quarts). In large 
effusions the adjacent organs may be displaced. If on the right side 
the liver is depressed. Osier says, as the result of many post-mor- 
tems : " Even in the most excessive left-side exudations, there is no 
rotation of the apex of the heart, which in no case was to the right 
of the mid-sternal line, and the relative position of the base and apex 
is usually maintained." 

Symptoms. — These are supposed to be well known, but there are 
many points which make a diagnosis difficult if we judge from symp- 
toms alone. The pain in the side, the most distressing symptom, is 
usually referred to the nipple or axillary region, but this pain may 
arise from inter-costal pleurisy, rheumatism, or myalgia. Dr. Inman 
has shown in his work on myalgia that a severe pleurisy may run 
its course without the pain in the side, supposed to be characteristic 
of pleurisy. Again, as Osier observes, pleuritic pain may be felt in 
the abdomen or low down in the back when the diaphragmatic sur- 
face of the pleura is involved. The pain, wherever it is, is sharp, 
stitching, or lancinating, aggravated by movement or coughing and 
inspiration. The same may occur in inter-costal neuralgia or myal- 
gia. The only trustworthy diagnostic sign is the rubbing sound on 
auscultation, and this can be detected at an early stage. 

The fever rarely rises so rapidly as in pneumonia, and does not 
reach the same grade. The average temperature is 102° to 103°. 
It may drop to normal in a week or ten days, or may persist sev- 
eral weeks. Cough is an early symptom, but is not as severe as in 
pneumonia. It is sometimes entirely absent. The expectoration is 
slight, mucoid, and only occasionally streaked with blood. There is 
some dyspnoea at first, partly due to fever, and partly to pain. Later 
it arises from compression of the lung. But when the fluid is effused 
slowly, one lung may be entirely compressed without inducing short- 
ness of breath, except on exertion. If the effusion is great, the 



DISEASES OF THE RESPIRATORY SYSTEM. 355 

patieut usually prefers to lie on the affected side. I omit the phys- 
ical diagnosis, referring the reader to those works which treat of it 
exhaustively. 

The severe pain on coughing and breathing can be alleviated by 
fixing the muscles of the thorax by a firm, smoothly applied bandage 
or careful strapping with long strips of adhesive plaster, which 
should pass well over the middle line, drawn tightly and evenly. If 
one side only is affected the strapping can be confined to that side. 

Treatment. — A correct diagnosis is very important. The proper 
selection of the remedy depends upon it. We have but few rem- 
edies homeopathic to pleural inflammation with effusion ; while we 
have many that are indicated in rheumatic or myalgic pleurodynia, 
or inter-costal neuralgia. 

Aconite is always useful in the first stage, and should be given 
as long as the pulse is small, hard, and quick, and the temperature 
over 102°. Mild cases of pleurisy will run a brief course under the 
influence of aconite. 

Yeratrum viride or gelsemium are rarely indicated, and are more 
useful in pleuro-pneumonia, with a high temperature and great arte- 
rial excitement. 

Bryonia is the chief remedy in all stages of pleurisy when it 
runs its regular course. It is the one serous membrane medicament 
from the vegetable kingdom of the qualities of which we have much 
trustworthy clinical knowledge. We believe it has caused pleurisy 
because its pathogenesis has all the essential symptoms, and because 
there are pathological facts which show that the conclusions drawn 
from the symptoms are correct. The autopsies of the animals pois- 
oned by the Vienna provers showed that the pleurae were injected 
and full of serum, and other serous membranes injected. It has 
been said that before the time of Hahnemann bryonia was only used 
as an emetic and cathartic. This is an error, and Hahnemann 
doubtless had a knowledge of its value in chest affections which 
prompted him to prove it. 

In Mangeti's "Materia Medica," published in 1753, written in 
Latin, it is recommended for " purging serous and pituitous humors 
from the chest "; " senile asthma "; " dropsy, internal and external "; 
" sciatica " (dolorum ischiadicum), etc. Culpepper in his " English 
Herbal " (1800) says : " It mightily cleanseth the chest of rotten 



356 THE PRACTICE OF MEDICINE. 

phlegm, and wonderfully helpith an old strong cough, and those 
that are troubled with shortness of breath." He gives it the qual- 
ities we give arnica. " It is very good for them that are bruised 
inwardly, to help to expel the clotted and congealed blood." 

Hahnemann used at first the tincture (one-half alcohol, one-half 
expressed juice), one drop at each dose; later he recommended the 
18th dilution, and finally, when the high-potency idea took pos- 
session of him, directs only one drop of the 30th to be given, and 
not repeated for weeks. To-day bryonia is used in pleurisy not only 
by our school but by eclectics and others. Their experience in its 
use shows that Hahnemann was laboring under a mistaken belief 
when he declared it dangerous to use repeated doses of the 18th or 
30th in pleurisy, for it is now used by thousands of physicians in 
doses quite material without causing aggravations. Eclectic and old- 
school writers recommend one drachm to four ounces of water, a 
teaspoonf ul every half-hour in acute pleurisy. 

Dr. Goss (" Practice ") recommends two or three drops every 
two hours, aud I have known as much as iive drops of the tincture 
to be given every two hours without any other result than decided 
amelioration of the pain and cough. I never have observed any 
beneficial results from bryonia when used higher than the 6th. I 
usually use the 2x in pleurisy. 

Asclepias tuberosa got its common name " pleurisy root " from 
its use by the country people in this disease. It was considered the 
principal remedy by the " Botanic physicians " in the early part of 
this century. The eclectics made it a prominent member of their 
Materia Medica, and it is to-day with them a standard medicine 
in pleurisy. Since they have appropriated our bryonia, however, it 
has taken a second place. We have but two provings. One by 
Dr. Savery, of Paris, who took two drops of the tincture and did not 
repeat the dose, but recorded all the symptoms (many of them nat- 
ural sensations) experienced for six weeks. This proving is value- 
less. The other proving was made by the late Dr. Tom Nickol, 
who took from ten drops of the lx to sixty drops of the tincture, 
until notable symptoms were developed, some of them giving a good 
picture of a mild left pleurisy. It seems to be a lesser bryonia and 
is probably not adapted to severe cases. The fever is not as high 
and the effusion is probably serous. The symptoms are : " Acute 



DISEASES OF THE RESPIRATORY SYSTEM. 357 

pleuritic pain in right side with dry hacking cough and scanty 
mucous expectoration, better by bending forward and worse by 
motion," also " stitches to the right side, and up to the left shoulder ; 
severe pain in the muscles and joints, hot sweating skin with ameli- 
oration of the pain." 

Cantharis has lately been praised by Jousset as a remedy for 
pleurisy in the stage of effusion ; he extols it above all other drugs. 
Its special symptoms are said to be " a profuse serous exudation, 
dyspnoea, cough, palpitation of the heart, a tendency to syncope with 
heavy sweats and scanty urine." In the provings the subjective 
symptoms of pleurisy are scanty. But we know that in cases of 
poisoning in men, congestion of the brain and serous effusion on the 
surface is found, and that the peritoneum is inflamed. There is no 
record of its action on the pleura, but we may safely assume that it 
will cause inflammation there. The decided and undisputed benefit 
which accrues from blisters of cantharides in pleurisy, above all other 
kinds of blistering agents, would seem to show that it has some spe- 
cific action aside from the good effects of counter-irritation. Can- 
tharis benefits the effusion by its specific action when absorbed 
into the circulation. I am sure that I have seen prompt alleviation 
from pain on the application to the affected side of a few small 
blisters of the size of a dollar, when other medicines had not caused 
satisfactory improvement. 

Squill is undoubtedly a valuable remedy in pleurisy. It resem- 
bles cantharis as well as bryonia, having many symptoms in common 
with both. It is rarely mentioned among the remedies for pleurisy, 
and when it is mentioned the indications are poorly given. I have 
more confidence in it than I have in cantharis, especially in children 
whose pleurisies are rapid and dangerous. I consider it useful when 
the pleuritic affection is attended with capillary bronchitis caused by 
exposure to cold or dampness after eruptive fevers. The effusion is 
serous and forms rapidly, while the kidneys are very torpid and the 
heart rapidly failing in force. The following are the symptoms 
found in its pathogenesis and marked as characteristic : " Frequent 
irritation to a short dry cough, in four or five shocks, caused by tick- 
ling beneath the thyroid cartilage." " A violent sudden cough in the 
morning, with stitches in the side on every cough, with expectora- 
tion." " Cough in the morning, with profuse slimy expectoration." 



358 THE PRACTICE OF MEDICINE. 

" Cough, at first accompanied by expectoration." " Constant expec- 
toration of mucus." " Difficult or embarrassed respiration." "Fre- 
quently obliged to take a deep breath, which provokes cough." 
" Dyspnoea and stitches in the chest, which are most distressing on 
inspiration." " Oppression across the chest as if it were too tight, 
drawing pain in the chest. Sharp stitches in the scapular end of the 
clavicle during inspiration and expiration. Severe stitches near the 
sternum, extending downward so that he could with great difficulty 
get his breath. Compressive pain in the right side of the chest, end- 
ing in a stitch. Broad pressive stitches beneath the last ribs of both 
sides, lasting two days. On inspiration, jerking stitches in the right 
and left sides of the chest not far from the sternum. Stitches in the 
left and right true ribs at the same time, drawing stitches from the 
right true rib to the shoulder. Broad, blunt stitches in the last 
ribs of the left side, in the morning in bed, that wake him. A con- 
tracting stitch in the left side, just beneath the last ribs. Stitches 
in the left side." 

Senega is a close analogue of squill. A study of its pathogen- 
esis will show many symptoms which could hardly be caused by inter- 
costal pain alone, although many bear a close resemblance to rheu- 
matism of the chest. No obstinate case of pleurisy should be 
treated without referring to senega. Old-school authors mention 
squills and senega in pleuritic effusion, and imagine that they act 
only as diuretics, ignoring their homeopathic relation to the disease. 

Carbonate of potassium, so much vaunted in stitching pains, is 
supposed by some to affect the pleura, but I think all the stitches 
are in the muscles of the chest. It is a muscular tissue remedy, not 
a serous tissue remedy. The stitching pains in the side attending 
lung lesions are rarely in the pleura, but are sympathetic, and in 
the inter-costal nerves. If pleuritic pains occur as an extension of 
lung lesions the pleurisy certainly would not yield to carbonate of 
potassium. That it will palliate " stitches " in the side during 
chronic pulmonary troubles may be true, but the transitory nature 
of the " stitches " makes it a doubtful remedy in chronic pleurisy. 

Khus toxicodendron has no place in the therapeutics of pleurisy 
unless rheumatism is a complication. 

The belief that the serous effusion in pleurisy can be dissipated 
by diuretics is fallacious. It can be dissipated by active depletion 



DISEASES OF THE RESPIRATORY SYSTEM. 359 

of blood serum as described by Matthew Hay, as I have tried with 
success in many cases, not only of this disease but of peritonitis and 
pericarditis with effusion. The theory is that if the serum is 
abstracted from the blood, or if it is kept concentrated, the liquid 
will be absorbed from the lymph spaces, of which the pleura is one, 
to equalize the loss. To do this the liquid food of the patient should 
be greatly restricted. If there is no fever, a diet of meat with eggs 
and dry bread, and only eight ounces of milk or water, should be 
given. Then give the patient, if he is moderately robust, one or one 
and a half ounces of Epsom salts an hour before breakfast, in con- 
centrated solution. This produces copious liquid discharges and a 
rapid disappearance of the exudation. I have been surprised to 
observe how little it weakened the patient. In young persons, not 
robust, I give a tablespoonful of the concentrated solution every 
four or six hours, and find it amply sufficient. I have rapidly " run 
off " general dropsy from heart disease by this method, after digi- 
talis, apocynum, and diuretin failed. The former practice of giving 
iodides to stimulate the absorbents to take up the effusion has- been 
of doubtful utility. 

Pilocarpine and other perspiration-producing drugs, as well as 
the diuretics, have not been more successful. They may be useful 
auxiliaries, but nothing more. 

Aspiration of the fluid is the most thorough and satisfactory 
method, but it should be resorted to only when it is found that other 
means have failed. 

The following are the indications that call imperatively for the 
operation : (1) In all cases where there is complete filling up of one 
side of the chest. (2) In any case when even moderate effusion 
has lasted several weeks. (3) When the fluid reaches the clavicle 
the operation is imperative, even though the patient is comfortable 
and presents no sign of pulmonary distress. The presence of fever 
is no contra-indication, for often where the serous exudate is drawn 
off the fever abates. Aspiration may prevent death from a sudden 
attack of dyspnoea, or subsequent phthisis, or the wearing-out of the 
vital forces. It will prevent those tedious cases which end in spon- 
taneous evacuation of the fluid, or blood-poisoning from purulent 
matters gaining access to the circulation. 

Empyema is really a surgical affection, and should be treated as 



360 THE PRACTICE OF MEDICINE. 

such. When an exploratory puncture has shown that the fluid is 
purulent, it should be withdrawn, not by aspiration but by a free 
incision, and free drainage obtained. Irrigation is rarely necessary 
unless the contents are foetid. The practice of some surgeons of 
irrigating with carbolized oil is useless and dangerous. In two cases 
in which this method was practiced upon my patients by the sur- 
geon, who was selected by the patient, both died, more from the 
effects of the drug than from the operation itself. If any disin- 
fectant is used, some of the non-poisonous ones should be selected. 
Borated calendula or peroxide of hydrogen are both safe and efficient. 
The subsequent treatment is a point of great importance in facili- 
tating the closure of the cavity and in the distension of the lung on 
the affected side. The following method has been practiced with 
great success in the Johns Hopkins Hospital : The patient daily for 
a certain length of time, increasing gradually with the increase of 
his strength, transfers by air pressure, water from one bottle to 
another. The bottles should be large, holding at least a gallon each, 
and by the arrangement of tubes, as in Wolff's bottle, an expiratory 
effort of the patient forces the water from one bottle into the other. 
In this way expansion of the compressed lung is systematically prac- 
ticed. During this process the respiratory power can be greatly 
aided by the administration of tincture of erythroxylon coca and que- 
bracho, one drachm of the former with fifteen drops of the latter, 
mixed or alternated every four hours. During convalescence the diet 
must be of the most sustaining nature, and as liberal as the digestive 
organs can manage. Those medicines, like strychnine and hydrastis, 
which aid digestion, together with pepsin and pancreatin, should be 
prescribed in material doses. Cod-liver oil, with beef emulsions, and 
the hypophosphites, are often indispensible, especially if there is 
hectic fever. 



CHAPTER VI. 

DISEASES OF THE DIGESTIVE SYSTEM, 



DISEASES OF THE MOUTH. 

STOMATITIS. 

Simple Stomatitis is one of the commonest forms of inflamma- 
tion of the mouth. Frequent in all ages, it is more often met with 
in children, associated with teething, or derangements of the stom- 
ach. It may be limited to the gums and lips, or may extend to the 
surface of the cheeks and tongue.. It is an erythematous affection. 
There is at first redness and dryness of the mucosa, followed by an 
increased secretion with furred tongue, which is swollen and indented 
by the teeth. 

Treatment. — Adults should avoid all irritating, spiced articles 
of diet, as well as tobacco and spirits. Infants should be fed on 
bland fluids. A wash of weak borax, or boric acid, should be used ; 
and in severe cases a very weak wash of fluid hydrastis. 

Apthous Stomatitis (follicular stomatitis) is characterized by 
the appearance of small, slightly raised spots surrounded by red 
areolae. The spots appear first as vesicles which rupture, leaving 
small ulcers with grayish bases and bright red margins. They 
appear generally on the inner surfaces of the lips, the edges of the 
tongue, and the inside of the cheeks. This form is met with in chil- 
dren under three years of age, but is also often seen in adults ; they 
are popularly known as "canker spots," and are generally caused 
by derangements of the stomach, or appear during gastric fevers. 
It must not be confounded with " thrush." 

Treatment. — I have had the best results follow the touching each 
one with a one per cent solution of nitrate of silver, and in severe 
cases with dilute nitric acid. A wash of chlorate of potassium or 
Phytolacca, ten per cent, aids in their removal. 



362 THE PRACTICE OF MEDICINE. 

Ulcerative Stomatitis, popularly known as " putrid sore mouth," 
often occurs in children after the first dentition. It sometimes pre- 
vails as an epidemic in unsanitary hospitals, camps, and jails. 
Unwholesome food, damp dwellings, unclean mouths, decayed teeth, 
and other causes lead to it. The morbid process begins at the mar- 
gin of the gums, which become red, swollen, and bleed easily. Ulcers 
form with a grayish-white base and firmly adherent membrane. In 
severe cases the teeth are loosened, and necrosis of the alveolar pro- 
cess may occur. Tongue, lips, and cheeks may be swollen and some- 
times ulcerated. There is salivation, the breath is foetid, mastica- 
tion is painful, and the sub-maxillary glands are swollen. It cannot 
readily be distinguished from the effects of mercury, and is often 
caused by the prolonged use of that drug. 

Treatment. — If not caused by mercury, the best remedy is mer- 
curius corrosivus, 6x, a dose three times daily, and a wash of chlo- 
rate of potassium, one drachm to a pint of water. If caused by mer- 
cury give hepar sulphur, and use the same wash of the chlorate, 
ordering that a tablespoonful of the solution be swallowed every four 
hours. If the breath is very offensive, give a wash of peroxide of 
hydrogen, five volumes. 

Stomatitis Materna, or the sore mouth of nursing women, is an 
obstinate and distressing affection. It may take the form of a dif- 
fuse erythema, or a follicular inflammation, and is caused either by 
debility from lactation, or by unwholesome surroundings. Very lit- 
tle has been written about it, neither Guernsey, Leavitt, Richardson, 
Lusk, or any other author I have consulted, mentioning it. I have 
seen many cases, some of them of a very serious character, which 
undermine the health so greatly that weaning the child becomes 
imperative. In the worst cases the gums and whole buccal cavity 
were red, dry, and ulcerated. The tongue was denuded of epithelum, 
and was glazed and stiff ; even the pharynx became invaded. Some- 
times I have been able to arrest it by nitric acid, cinchona, tincture 
of the chloride of iron, or hydrastis ; with a wash of dilute nitric 
acid or nitrate of silver ; but generally a cure was impossible until 
lactation was suspended. Then the result was surprising; the 
mouth getting well in a few days, and the patient's strength return- 
ing rapidly. 

Parasitic Stomatitis (thrush, muguet). — This disease is depend- 



DISEASES OF THE DIGESTIVE SYSTEM. 363 

ent on a fungus — the oidium albicans — a species of yeast fungus, 
and consists of branching filaments from the ends of which ovoid 
torula cells develop. It does not attach itself to normal mucous 
surfaces, but is caused by improper food, uncleanliness of the mouth, 
and unclean bottles, spoons, etc. It is not confined to children, but 
attacks adults in the final stage of fever, in chronic tuberculosis, 
diabetes, and cachectic states. The parasite develops in the upper 
layers of the mucosa, and filaments penetrate the epithelial cells. 
The disease may begin on the cheeks, tongue, or lips, in the form 
of slightly raised white spots, which increase and finally coalesce. 
When scraped off it leaves the mucosa intact, or if severe, a red, 
bleeding surface, which may ulcerate. It may extend downward 
through the whole digestive tract and even into the air-passages. 
It is sometimes transmitted to the mother's nipples, and to her mouth 
from kissing the child's lips, and to other children who use the same 
spoon. 

Kobust infants sometimes have a touch of it, but it generally 
affects delicate feeble children artificially fed. 

Treatment. — It is more easily prevented than cured. All the 
utensils used by the child should be put to soak in a strong solution 
of borax, boric acid, or sulphite of soda, or washed in boiling water. 

Washes of borax, sulphite of soda, peroxide of hydrogen, or 
permanganate of potassium, not too strong, should be used after 
nursing or feeding. The health of the child should be improved by 
the use of phosphate of calcium, cinchona, or muriate of iron. It 
may be necessary to order a wet nurse if the child has been artifi- 
cially fed ; or to order the patient's removal to the country or sea 
coast. There is a form of muguet which is generally seen in old 
people. The fungus penetrates deeply into the tissues, and seems 
to affect small areas on the tongue. These spots swell and protrude, 
and look like fungous granulations, bleeding easily. The tongue is 
swollen, pale, and flabby, and assumes a bluish appearance. Muri- 
atic acid strong enough to taste sour, used as a wash and swallowed, 
is specific. 

Gangrenous, Stomatitis (cancrum oris). — This terrible disease 
is seen only in children who live in very unsanitary conditions, or in 
those convalescent from measles, scarlet fever, and typhoid fever. 
It is a rapidly progressing gangrene, starting on the gums or cheeks, 



364 THE PRACTICE OF MEDICINE. 

and leads to extensive sloughing and destruction. In some eases 
the cheeks are perforated. It may spread to the tongue and chin, 
and invade the bones of the jaws, eyelids, and ears. The pulse is 
rapid and weak, the prostration extreme, the odor horribly offensive. 
A diarrhoea may supervene. Death may occur within a week or ten 
days. It is supposed to be caused by a bacillus. It may appear so 
insidiously that extensive sloughing is present before it is noticed. 

Treatment. — Unless seen in the early stage it is difficult to pre- 
vent dangerous consequences. Several cases have been reported 
cured by the continuous application of subnitrate of bismuth. The 
gallate of bismuth, perhaps, would be equally useful. Destruction 
of the sore by fuming nitric acid or Paquelin's cautery has arrested 
the disease. In mild cases boric acid applied in powder may be 
useful. A wash of thymo-hydrastis, baptisia, or peroxide of hydro- 
gen (ten volumes), should be used. Internally, arsenic 3x, cinchona 
mother tincture, or cyanide of mercury 6x should be given. The 
food should be strong and liquid. Valentine's meat juice, beef tea 
acidulated with muriatic acid, or yelk of eggs beaten up with brandy 
must be given frequently. 



DISEASES OF THE SALIVARY GLANDS. 

Hypersecretion (ptyalism) may arise from the use of mercurials, 
for which belladonna, hepar sulphur, aurum, and phytolacca are 
useful ; aided by a strong wash of chlorate of potassium, with ten 
grains internally several times a day. If it occurs in mental and 
nervous affections, pilocarpine 6x will probably arrest it. With this 
remedy I have cured several severe cases occurring during pregnancy 
and accompanied by distressing nausea. It sometimes occurs during 
the menstrual period, and from sexual erethism. If idiopathic, some 
mercurial preparation is usually specific. 

Xerostomia (dry mouth) is a condition in which the secretions 
of the mouth are suppressed. The tongue is red, cracked, and dry, 
the mucous membrane of the cheeks and palate is smooth, red, 
shining, and dry ; swallowing and articulation are difficult. In some 
cases the general health is unimpaired. It may be due to impair- 
ment of some centre in the medulla which controls the secretion of 
the glands. I have seen it occur from intense and sudden grief. 



DISEASES OF THE DIGESTIVE SYSTEM. 365 

When of a purely nervous origin, pilocarpine 2x will cure nearly 
every case. Occasionally belladonna or lachesis will cure. It is 
common in septic fevers, and is then ominous, although in several 
instances I have restored the secretions permanently with pilocarpine. 
Baptisia is excellent in mild cases. Osier reports a case cured by 
the galvanic current. 

Parotiditis (mumps) has been treated of under Infectious Dis- 
eases. 

DISEASES OF THE TONSILS. 

Acute Tonsilitis. — The various forms which have been called 
catarrhal, erythematous, ulcero-membraneous, and hepatic, may for 
all practical purposes be considered together. It is commonly caused 
by exposure to cold and wet, aided by bad hygienic surroundings. 
In cities a large proportion of cases is caused by defective drainage. 
When several persons in the same building are attacked I always 
order the sewer pipes to be examined, and nine cases out of ten some 
defect is found. I believe that certain ptomaines generated in the 
intestinal canal will cause tonsilitis. It sometimes appears to have 
some connection with rheumatism, and with disorders of the sexual 
system, but this connection is not yet fully proven. The symptoms 
are soreness of the throat, pain on swallowing, and fever which often 
reaches 105°. On examination the tonsils are found swollen, and 
there is a creamy exudation from the crypts. The tongue is furred, 
the breath is heavy and foul, the urine is high-colored and loaded 
with urates. Swelling of the cervical glands is usually present. In 
severe cases the exudation forms cheesy-looking products, appearing 
like the heads of shoe pegs, the exudations sometimes coalescing. 
This is the form so often supposed by ignorant or careless physicians 
to be diphtheria, and when reported to medical societies forms the 
majority of those " hundreds of cases cured by various medicines." 

When the exudation covers the tonsils it may be difficult to dis- 
tinguish it from true diphtheria, but the yellowish-gray masses in 
tonsilitis differs from the pearly or ashy-gray membrane of diph- 
theria. In tonsilitis the patches never creep up the pillows of the 
fauces or appear on the uvula. The diphtheritic membrane when 
removed leaves a bleeding, eroded surface, but the exudation in ton- 
silitis is easily separated, leaving no erosion. There is no doubt, 



366 THE PRACTICE OF MEDICINE. 

however, that this condition of the tonsils affords a fertile field for 
the growth of the bacillus of Loef&er. Jacobi lays much stress on 
this fact, and I have seen several cases that were undoubtedly follic- 
ular tonsilitis, and had nearly run their normal course when the true 
diphtheritic membrane suddenly appeared. This complication should 
be carefully watched for, and prevented by the use of washes of 
thymol-hydrastis and peroxide of hydrogen. 

In Suppurative Tonsilitis (quinsy) the inflammation is deeper- 
seated and involves the stroma. The constitutional disturbance is 
greater, and high fever with nocturnal delirium is not uncommon. 
The tonsils rapidly enlarge and reach such a size that they meet in 
the middle of the throat, or when only one is affected, it may push 
the uvula aside and touch the other tonsil. They are firm, dusky- 
red, cedematous, and very sensitive to the touch. There is a profuse 
flow of saliva, glairy and tenacious. The lower jaw is fixed, and the 
mouth can with great difficulty be opened. In from three to six 
days the enlarged gland becomes softer, and sometimes fluctuation 
can be felt by placing one finger on the tonsil and the other at the 
angle of the jaw. The abscess usually points into the mouth, or 
toward the pharynx. It may burst spontaneously, affording instant 
relief, but cases are on record where it has burst into the larynx, 
causing death by suffocation. 

Treatment. — For follicular tonsilitis, if seen during the stage 
of high fever at the onset, aconite is specific ; but it will not arrest 
or modify the inflammation unless it is given in the lx, a drop every 
hour in children, and ten drops for an adult. After the first few 
hours alternate it with proto-iodide of mercury 2x. Phytolacca 
rivals the latter in some cases, especially when the spots coalesce, and 
seem pseudo-membraneous ; it is for this appearance that phytolacca 
has won a reputation in diphtheria, for I do not consider it a true 
diphtheritic remedy. These remedies alone will conduct nearly all 
cases to a favorable termination. A spray of trypsin or papoid will 
dissolve the exudation when it is excessive. 

In Parenchymous Tonsilitis other medicines are more appropri- 
ate, in addition to aconite. It is claimed that rubbing into the ton- 
sils bicarbonate of soda will abort quinsy, but I have not found it so ; 
although I have seen amelioration follow the rubbing in of the salicy- 
late and bisulphite of soda, and alternating either of them with aco- 



DISEASES OF THE DIGESTIVE SYSTEM. 367 

nite, in doses of three grains every two hours. If great pain in the 
tonsils and contiguous tissues is present, phenacetin, two grains 
every hour, gives decided relief, much better than morphine. If there 
seems to be some connection between this disease and rheumatism, and 
if the urine is loaded with uric acid or urates, give benzoic acid lx 
or the benzoate of lithia lx. I have seen good results follow the 
use of three grains of salol ; or guiacum, five drops in a teaspoonful 
of milk or maltine, given every two hours. 

Dr. R. Hughes and others believe that the carbonate or muriate 
of barium will prevent suppuration, but I have not been fortunate 
with it, although I have used it in the 3x, 6x, and 12x. In my 
earlier practice I believed I aborted cases of suppurative quinsy with 
lachesis, but it has lately disappointed me. Several years since, I 
was told by several patients that if as soon as they noticed the first 
symptoms of quinsy they took five grains of calomel or three grains 
of blue mass (following either in six hours with a seidlitz powder, 
if in that time no purgative action appeared) the quinsy would surely 
be aborted. I requested them to try it, and the result surprised me. 
Since then I have tested the practice many times, with the result 
that in one-half the cases the inflammation was apparently arrested. 
At any rate it always ran a mild course, and was not attended by 
suppuration. If suppuration seems inevitable, give hepar sulphur 
2x, a tablet, or two grains of the trituration, every hour, to hasten 
that process. Old-school authorities use the lx of calcium sulphide 
with very gratifying results. A gargle of thymol-hydra stis or per- 
oxide of hydrogen should be used, after the abscess is open, and 
until it ceases to discharge. If possible, open the abscess, but I con- 
fess I have rarely been successful in the attempt to do so. There is 
some danger of cutting the internal carotid artery. This perhaps 
has prevented me from cutting deep enough. 

Chronic Tonsilitis. — This maybe defined as an enlargement 
and induration of the tonsils, with chronic naso-pharyngeal obstruc- 
tion and mouth-breathing. Osier considers under this head, hyper- 
trophy also of the adenoid tissue in the vault of the pharynx, some- 
times known as the pharyngeal tonsil, " because both these tissues 
are involved and are not to be differentiated."' 

This affection is now considered of great importance, as it may 
influence in an extraordinary way the mental and bodily develop- 



368 THE PRACTICE OF MEDICINE. 

ment of children. The tonsils may be in a condition of hypertrophy, 
due to a multiplication of all their constituents ; or, in some instances 
the fibrous matrix is increased, and then the organ is harder, smaller, 
firmer, and cut with great difficulty. The adenoid growths which 
spring from the vault of the pharynx form masses varying in size 
from a small pea to an almond. They may be sessile, with broad 
bases, or pedunculated. They are reddish in color, and contain 
numerous blood-vessels. They are more frequently nipple-like, with 
a lymphoid parenchyma ; chronic nasal catarrh usually coexists. 
The direct effect of these hypertrophies is the establishment of 
mouth-breathing, a deformity of the thorax known as " chicken- 
breast," a changed facial expression, and a kind of mental hebe- 
tude. The mouth-breathing is not so noticeable during the day, 
but at night the child's sleep is greatly disturbed ; the respirations 
are loud and snorting, and there are sometimes prolonged noisy 
inspirations. The child may wake up with symptoms like spasm 
of the glottis. The expression of the face is dull, heavy, and apa- 
thetic, partly due to the fact that the mouth is left open. The 
child is stupid-looking, responds slowly to questions, and may be 
sullen and cross. In school they are considered "dunces." The 
lips are thick, the nasal orifices small and pinched, the roof of the 
mouth is arched and higher than normal. This condition is said to 
cause stuttering. The hearing and sense of taste and smell are 
dulled. Incontinence of urine may exist as a part of the abnormal 
state. Headache is an almost constant symptom. Foetor of the 
breath is present, and is caused by retained secretions, or by the 
cheesy exudations from the crypts of the tonsils. Such children are 
most liable to diphtheria and scarlet fever, and in them it causes a 
violent and malignant sore throat. 

Treatment. — I doubt if it is possible to remove the enlarged ton- 
sil or adenoid growths by medicines, although I have seen improve- 
ment follow the continued administration for weeks of iodide of 
barium or thuya. If the child presents all or nearly all the symp- 
toms above mentioned surgical interference is necessary. The 
enlarged tonsils must be cut down, not cut out. When shaved off 
they will contract and be absorbed under the influence of iodine or 
chromic acid. The former can be used with a brush, full strength ; 
the latter cautiously, a fifty per cent solution, a mere film applied 



DISEASES OF THE DIGESTIVE SYSTEM. 369 

once a day, and none allowed to be swallowed. If the cutting oper- 
ation is not permitted the crypts should be cleaned out with a small 
curette, and the cavities touched with aristol, iodine, nitrate of sil- 
ver, or eucalyptol. The removal of the adenoid growths should be 
insisted on. 

Parents should be informed that the trouble is serious, and if not 
removed will endanger the mental and physical health of the child. 
The operation is easily performed. The patient should be ether- 
ized, when the growths can be readily removed with the finger-nail, 
or a suitable curette, not too sharp. Great improvement follows in 
a few days, which is sure to satisfy the parents of the importance of 
the operation. If the lower jaw still drops, as it may do from habit, 
a chin strap should be applied at night to hold it up. It may be a 
long time before the child can articulate clearly and distinctly. If 
possible give the child cod-liver oil with syrup of iodide of iron, or 
iodide of iron 2x, with phosphide of zinc 3x. 



DISEASES OF THE (ESOPHAGUS. 

Inflammation of the oesophagus is not a rare disease, though it is 
not often recognized. It may be caused by extension of catarrhal 
inflammation from the pharynx ; by such chemical irritants as sul- 
phuric acid, carbolic acid, caustic ammonia, phosphorus, etc.; by 
drugs, tartar emetic (pustular), veratrum, and gelsemium (erythe- 
matous); by very hot liquids ; by extension of diphtheria, and dur- 
ing small-pox. 

The symptoms are pain on swallowing referred to the space 
behind the sternum, the food seeming to lodge there. 

The treatment is not very satisfactory. In two cases caused by 
gelsemium, phosphorus relieved. Barium helps when the food causes 
pain just above the cardiac orifice of the stomach. Belladonna 
ought to be beneficial ; swallowing bits of ice, or eating ice-cream 
slowly is very grateful to the patient. 

Spasm of the oesophagus, or spasmodic stricture, is met with in 
hysterical or hypochrondriacal patients, in chorea, epilepsy, and 
hydrophobia. It may be present during pregnancy. It may be 
caused by grief. 

Naja, according to Hughes, is a very useful remedy. Ignatia and 

24 



370 THE PRACTICE OF MEDICINE. 

asafcetida are the remedies for hysterical men and women. The 
oesophageal spasms of women are benefited by chloroform water, a 
teaspoonf ul every hour. 

Baptisia if only water can be swallowed. Muriate of sodium and 
bromide of potassium when only solids can be swallowed. Hydro- 
phobium ought to be useful in this condition. 

Arsenic when the oesophagus seems to cramp — also cocculus. 

Aconite has been beneficial, also belladonna, hyoscyamus, and 
lachesis. 

In some cases a cure follows the single passage of a bougie, 

Gelsemium is homeopathic to alternate spasm and paralysis of 
this tube. 



DISEASES OF THE STOMACH. 
ACUTE GASTRITIS ACUTE GASTRIC CATARRH. 

This is one of the most common of complaints. It generally 
arises from errors of diet ; eating too much food of any kind ; eating 
partially decomposed or very irritating food ; a few spoonfuls of 
highly-seasoned soup may bring it on ; an American or Englishman 
cannot eat the foods of Spain and Mexico, highly seasoned with 
pepper, for the first time without the danger of an attack ; alcohol is 
a common cause ; a fright, or mental labor just after eating, will in 
many persons cause an attack ; finally, I believe it may appear as a 
result of a common cold attacking the stomach first before any other 
mucous surface. 

The appearance of the stomach, according to Beaumont's observa- 
tion in the case of St. Martin, who had an opening into that organ, 
showed that in acute catarrh the mucous membrane is reddened and 
swollen, less gastric juice is secreted, and mucus covers the surface ; 
slight hemorrhages and even erosions may occur. Mild cases last 
not more than twenty-four hours, and are attended with headache, 
nausea, eructations, and vomiting which gives relief by expelling the 
contents of the stomach. The tongue is heavily coated, and there is 
an increase of saliva, with a sensation of dryness of the mouth. In 
many cases there are intestinal symptoms, colic, and diarrhoea, espe- 
cially in children. 

In severe cases fever attends it. The temperature may rise to 



DISEASES OF THE DIGESTIVE SYSTEM 371 

102° or 103°, with quick pulse. There may be in children delirium 
and convulsions. The tongue is heavily furred, yellow or brown, 
with offensive breath. The vomiting may be severe — a continuous 
rejection of food and water, and ejection of mucus and bile, or mucus 
tinged with blood. The region of the stomach may be tender to 
the touch, and the abdomen distended. Herpes may appear on the 
lips. The fever may last five or seven days. Some writers doubt 
the existence of a gastric fever, and call it a mild or aborted typhoid, 
but I believe there is a true fever from gastric inflammation. 

Treatment. — If there is reason to suppose that the stomach con- 
tains irritating or fermenting food it should be cleared out by a warm- 
water emetic, or apormorphia, one-tenth of a grain. It is better in 
some cases to give a dose of castor oil, or five grains of mercurius 
dulcis, than to allow it to remain in the stomach or pass into the 
bowels and remain there undigested. 

For the fever aconite or gelsemium is generally sufficient. The 
irritation of the mucous coat of the stomach should be allayed by 
lime water and milk, equal parts, or hot water. Water sipped as 
hot as can be borne is more effectual in arresting the vomiting: and 
pain in the stomach than is generally supposed. It has removed 
very grave symptoms in some of my patients after the failure of 
medicines. Some patients are benefited by ice pills, others by iced 
apollinaris or Yichy water. A favorite remedy in cases of children 
is the following : 

R Bismuth drin. i. 

Chloroform, water oz. i. 

Cocaine gr. i 

Distilled water oz. iii. 

A teaspoonful every hour. 

It is useless to name many medicines for this condition. 

Arsenic is valuable in severe cases that threaten to end in ero- 
sion or ulceration. The intense thirst, constant vomiting', burninof 
pain, anxiety, and prostration, indicate it. 

Ipecac will control mild cases characterized by nausea and vom- 
iting. 

Iris versicolor is useful in many cases when arsenic is prescribed 
in a routine manner. It is especially useful in acid vomiting with 
headache over the eyes. 



372 THE PRACTICE OF MEDICINE. 

Mercurius dulcis 2x, a grain every hour, will cure a majority of 
all cases in children ; for adults the lx should be prescribed. 

Nux vomica is the best remedy when indigestible food or aichohol 
is the cause. 

Yeratrum album is often indicated, aud its symptoms should be 
carefully compared with arsenic. 

Nitrate of silver 3x has cured some very bad cases. 



CHRONIC GASTRITIS— CHRONIC CATARRH OF THE STOMACH- 
CHRONIC DYSPEPSIA. 

The conditions above named may be defined as a chronic state of 
disturbed digestion, associated with an increased quantity of mucus ; 
qualitative or quantitative changes in the gastric juices ; enfeeble- 
ment of the muscular coats of the stomach, whereby the food is 
retained in that viscus longer than is normal ; and finally, abnormal 
changes in the structure of the mucous coat of the stomach. 

Causes. — It generally supervenes on acute attacks of acute gas- 
tritis, or it may come on slowly and insiduously from — 

(1) Improper habits — viz : Unsuitable and improperly cooked 
foods ; the use in excess of fatty foods ; of tea, coffee, or alcohol ; 
eating at irregular hours ; eating too much, rarely eating too little ; 
eating too rapidly and chewing the food too little ; drinking too cold 
or too hot drinks ; the injurious habit of drinking ice-water at meals ; 
the excessive use of tobacco ; lunches between meals, before the food 
of the previous meal is out of the stomach. 

(2) Anaemia ; Bright's disease ; chronic heart disease ; cancer, 
ulcer, and dilitation of the stomach ; engorgement of the portal cir- 
culation ; and mental emotions of a depressing nature. 

(The pathological changes are fully described in recent text- 
books.) 

Symptoms. — Impaired and variable appetite, distress and oppres- 
sion after meals in the epigastrum or under the lower half of the 
sternum ; tenderness over the region of the stomach ; coated tongue, 
bad taste in the mouth, the tips and margin of the tongue red ; 
increase of the pharyngeal secretions ; pyrosis ; rising of burning, 
scalding fluids in the oesophagus ; nausea in the morning or after 
meals ; burning eructation of gas and bitter sour fluid, with particles 



DISEASES OF THE DIGESTIVE SYSTEM. 373 

of food ; a fermentation of food that remains in the stomach too 
long ; constipation, or diarrhoea of undigested food : headache, mel- 
ancholia, vertigo, irritability of temper, cough, sleeplessness, or ten- 
dency to sleep during the day. These are a few only of the multi- 
tude of symptoms. Each case should be studied by itself, no two 
being alike. No two cases require the same diet or medicines ; there 
is no routine successful treatment. 

Treatment. — The treatment of chronic dyspepsia may be divided 
into (1) dietetic ; (2) hygienic ; and (3) medicinal. 

(1) The patient must eat regularly, but not too much. The food 
should be well masticated, well-cooked, neither under-done nor over- 
done ; not over eight ounces of fluid should be taken with the meals, 
and this toward the end. The variety of food should be limited ; 
too many courses are injurious ; not over one drachm of alcohol (in 
wine or other liquor) should be taken during or after meals, none at 
all at breakfast or lunch, except for special reasons, and tobacco 
should not be smoked before meals. 

There are no cast-iron rules of diet, for " what is one inan'-s food 
is another man's poison." Pepsin and other digestives should be used 
very judiciously. In old and bad cases a rigid milk diet should be 
tried. If the patient asserts that he cannot bear milk, he is mistaken. 
He may not be able to drink milk with his meals, but he may be 
able to use it alone as a food. He may not be able to digest it in 
its ordinary condition, but may digest it well when violently shaken 
for a minute. If he cannot digest milk, buttermilk or koumiss may 
digest perfectly, or milk may digest well if mixed with equal parts 
of Vichy or other alkaline water, or even if slightly salted. In 
some cases it is best to remove the cream. In other cases cream and 
water should be used. Milk should always be taken warm, and 
sipped slowly. In whatever form it is used, milk should be taken 
in definite quantities and regularly, six to eight ounces every three 
hours. Peptonized milk will not suit all cases. It does not agree 
with a patient that has a dilated stomach. The stools should be 
watched, and if undigested milk appears in them, eggs or some fari- 
naceous food should be added. If the milk diet does not cure, we 
must ascertain by the process of exclusion what articles of diet agree 
or disagree. A cure may be effected by cutting off one or more 
articles of food. The first thing to be excluded is hot bread. This 



374 THE PRACTICE OF MEDICINE. 

is a prominent cause of chronic dyspepsia. Replace it with good 
bread twenty-four hours old, and all the rest of the meal may be 
well borne. If not, try " Zweibach," or thoroughly toasted bread, 
not held before a fire, but baked in a hot oven so that the starch is 
changed to glucose. If this does not suffice, cut off all pastry. A 
well-made pie is not indigestible, except in some instances. Tarts, 
cakes, pancakes, ice-cream, and rich puddings should all be excluded 
in bad cases ; or one after the other until we are satisfied which 
gives offense. Sugar and certain acids may have to be forbidden. 
Rich, high-seasoned, or greasy soups are generally bad. The fat of 
bacon and good butter rarely disagree. Certain fruits always dis- 
agree with some persons. Fruit should not be eaten after dinner, 
but as a rule at the beginning of a breakfast or lunch. The above 
are only suggestions, hints which may serve as a guide in the study 
of individual dietetics. 

Hygienic. — Mental influence goes a great way in the treatment 
of dyspepsia. The victim is usually morbidly introspective. He 
eats without enjoyment because he fears each dish will disagree. 
After the meal is over he watches for pain or discomfort to follow. 
If he eats alone, matters are worse. He should eat in cheerful com- 
pany and keep his mind off his food after selecting the dishes, and 
not think of them after he has eaten them. Cheerful conversation 
during and after meals is an enemy to dyspepsia. Many of the most 
confirmed dyspeptics have been cured by going into the pineries and 
eating pork and beans with corn bread among the rough wood-cut- 
ters who make meal-time a season of laughter, jokes, and pranks. A 
dyspeptic will go fishing or hunting and eat the hardest fare without 
a twinge of gastralgia. The same food eaten at home would require 
the services of a doctor. Of course I do not imply that a patient 
with an ulcerated or eroded stomach can be benefited by such a 
regimen, but the dyspepsia from purely functional causes, however, 
can be benefited, for in such cases the mind has a great influence. 
Patients should not exercise much or violently after meals. Repose 
is the law of nature. The man who dozes after dinner is rarely a 
dyspeptic. Nor should a dyspeptic engage in mental labor after 
meals, for when the brain is excited the blood is attracted to that 
organ and away from the stomach, which should be slightly turges- 
cent during digestion. Light reading, a novel or the newspapers, 



DISEASES OF THE DIGESTIVE SYSTEM. 375 

should be the extent of the mental exercise. A change of air or a 
change of occupation does wonders for some dyspeptics. 

Medicinal. — There is scarcely a drug in the materia medica but 
has in its pathogenesis some dyspeptic symptoms. In rare cases any 
one may be indicated. Lilienthal gives the symptoms of more than 
one hundred, yet of all of them there are only few of any consider- 
able value. The following are meutioned in the order of their 
importance : nux vomica or strychnine, arsenic, euonymin, abies, 
ignatia, arnica, hydrastis, antimony, aurum, bismuth, bryonia, carbo 
vegetabilis, chelidonium, china, helonias, creosote, lycopodium, mer- 
curius corrosivus, muriatic acid, nitric acid, podophyllum, pulsatilla, 
iris versicolor, sanguinaria, sulphur, and anacardium. The special 
symptoms are so admirably given by Lilienthal that I refer the 
reader to his " Therapeutics." 

My own experience with medicines may be of value, but I can 
give only a brief resume. As arsenic is the typical remedy in acute 
gastritis, so it is in the chronic form. It is capable of causing all 
the phenomena of imperfect, slow, and painful digestion. Its- action 
is primarily on the mucous membrane, which it irritates to such an 
extent that an abnormal amount of mucus is thrown off, and becomes 
itself an irritant ; all arsenical catarrhs are acrid and irritating, the 
mucosa is injected, and after a time becomes eroded and ulcerated. 
Gastric pain is often violent and attended by sudden prostration, and 
occurs after taking food. The pain is burning, often confined to 
one spot ; there is pain and pressure in the large end of the stom- 
ach, which may radiate up the oesophagus and to the heart ; there 
is great thirst, but the patient is often able to take only a little fluid 
at one time. In no form of gastritis does the general system suffer 
so much as in the arsenical. We know that arsenic causes periph- 
eral neuritis, ending in paralysis. Its action on the nerves of the 
stomach is of this character. Its final action is to cause atrophy of 
the gastric glands with destructive lesions of the mucous coat attended 
by paresis of its nerves. 

A study of its pathogenesis will show all these varied conditions* 
When we have selected arsenic for a chronic gastritis, the choice of 
the preparation is important. I prefer Fowler's or Valengin's solu- 
tion, one drop of 3x. The lx should be made with water, above 
that with alcohol. The dilution selected will depend on the amount 



376 THE PRACTICE OF MEDICINE. 

of irritation in the stomach. In rather torpid, chronic cases of 
drunkards, the crude drug acts well ; in severe cases the 3x or 6x. 

I consider nux vomica and its alkaloid, strychnine, to be indicated 
in a majority of cases, not only by their symptoms but by their 
physiological effects. It is well known that the secretion of gastric 
juice is under the control of the nerves which supply the stomach, 
and that these nerves are in turn controlled by reflex influence from 
other organs, chiefly the brain. 

Nux vomica exercises more control over all these nerves than 
does any other drug. Experiments have proved that strychnine 
increases the amount of gastric juice, as well as the movements of 
the muscular coats of the stomach, consequently it increases the 
digestion, and also the assimilation of foods. In dilatation of the 
stomach it acts as marvellously as it does it dilatations of the heart. 
There is only one contra-indication for it, namely : when there is an 
excess of gastric juices ; and possibly a high dilution might be indi- 
cated in that condition. Some cases respond to nux vomica, others 
are better affected by strychnine. Do not be afraid to use nux in 
one to five drop doses of the tincture in adults ; nor the one-fiftieth 
of a grain and upward of strychnine. They act best when given 
shortly after eating. When the gastric juice as well as the muriatic 
acid is notably diminished, it is necessary for a time to give this 
digestive acid in connection with the nux vomica. One of the most 
successful of all formulas is : tincture of nux vomica, two drachms ; 
strychnine solution, one grain ; pure pepsin, four drachms ; dilute 
muriatic acid, four drachms ; glycerine, one ounce ; distilled water, 
seven ounces. Give a teaspoonful before or just after meals. 

Ignatia may be substituted for nux vomica in some eases, espe- 
cially in women. When the catarrhal condition of the stomach is 
extreme, and the patient vomits mucus alone or mixed with food, 
hydrastis may take the place of nux vomica. Sometimes the white 
alkaloid acts better than the tincture, in doses of one-tenth of a grain 
to each teaspoonful of the above mixture. 

Bismuth equals nux vomica in its power over dyspepsia, but its 
sphere is different. It is a sedative to the nerves of the stomach, 
and is indicated in those cases where the prevailing sensations are 
pressure as from a weight in the stomach, with constant eructations, 
lasting until the stomach is empty. One drachm of the crude drug 



DISEASES OF THE DIGESTIVE SYSTEM. 377 

can be added to the above formula, leaving out the nux and muriatic 
acid. The pain of bismuth occurs very soon after meals, that of 
nux and its congeners not for an hour or two after. There is 
another group of medicines that cause painful sensation after the 
stomach is empty, which are relieved by eating again : anacardium, 
arnica, chelidonium, turpentine, lachesis, petroleum, all have this 
symptom. 

The medicines of most value when flatulence in the stomach is 
the principal symptom are : muriate of sodium (2x, up to using it 
freely on food), lycopodium (mother tincture to 30th), carbo vege- 
tabilis (ten grains of the crude drug to the 3x), creosote (2x), salicy- 
late of soda (one to three grains), oil of wintergreen (lx or mother 
tincture), bismuth, and mercurius dulcis (lx to 3x). 

When there is an excess of acids other than muriatic, iris versi- 
color, podophyllum, sanguinaria, robinia, carbonate of calcium, nux 
vomica, and Pulsatilla, are the homeopathic remedies. If these fail 
use the vegetable or mineral acids. Sour fruit without sugar, cider, 
lemon and lime juice, nitric and phosphoric acids, and even soured 
beer has effected cures ; carbolic acid, thymol, boric acid, sulphite 
or sulpho-carbolate of soda, eucalyptus and other antiseptics have 
cured dyspepsia with formation of acid ferments. 

If muriatic acid is in excess, bicarbonate of soda or magnesia, or 
lime water, are effectual remedies. They unite with the acid, form- 
ing unirritating muriates of soda, lime, and magnesia. In the acid 
indigestion of children, lime water and the " milk of magnesia " are 
indispensable medicines, giving at the same time as radical curative 
agents, iris, carbonate of calcium, and rheum. 

Euonymin is one of the most potent remedies we possess for the 
so-called bilious dyspepsia ; the tongue is yellow, breath offensive, 
frontal headache, pale stools, bitter eructations, and slow pulse, indi- 
cating feeble circulation, especially in the portal system, call for 
this medicine ; when given in the lx to 3x triturate it rarely disap- 
points. If it does not cure, use its congeners, iridin, leptandrin, 
podophyllin, or salicylate of soda, in the same doses, giving a dose 
before meals and at night. 

Pancreatin, ptyalin, papayotin or papoid, and diastase are all 
useful, especially where the digestion of starch and fat is imperfect. 
Pancreatin should be combined with bicarbonate of soda, five grains 



378 THE PRACTICE OF MEDICINE. 

of each (tablets are preferable) given an hour after meals. Ptyalin 
is not much used. Diastase is an excellent remedy when starchy 
food ferments and sours in the stomach. A diastase solution in 
teaspoonful doses after meals, can be repeated if necessary every 
half-hour. " Malt with pepsin and pancreatin " is of great value in 
similar cases. Dose, a tablespoonful. 

Papayotin is prepared from the juice of the papaya, a native of 
Florida and the West Indies. It is the most powerful digestive of 
meats and starch yet known. It is the milky juice of the green 
fruit, which looks like a small melon. The leaves are said to con- 
tain it. Tough meat wrapped in the green leaves becomes tender 
in a few hours. While visiting on Merritt's Island in the Indian 
Kiver, South Florida, I met with an old physician who had lived 
there many years. He informed me that many confirmed dyspeptics 
had been cured by eating the ripe fruits and the seeds. These 
seeds are pungent and taste like mustard. A few eaten before and 
after meals enabled me to eat heartily of food which I did not dare 
eat without them. The juices of the fig, pineapple, and some other 
tropical fruits possess the same digestive principle. 

George Herschell, M.D., Physician to the Children's Hospital, 
London, writing of papoid, says : " It is to Dr. Finkler (Professor 
of Physiology at the University of Bohn), that the medical world is 
indebted for devising a preparation that is uniform in its effects. 
Finkler's papoid will digest 1000 to 2000 times its own weight of 
moistened fibrin when warm, and softens muscular tissues in half an 
hour. Although so powerful, living membranes are not acted on, 
and thirty to seventy-five grains have been administered to dogs and 
rabbits without untoward results. It acts in either acid, alkaline, or 
neutral solutions, and when it has come into contact with fibrin, 
adheres to it with such tenacity that no amount of washing will 
remove it or stop its action." 

For practical purposes, as a digestive ferment to be given medi- 
cinally, papoid presents the following advantages over pepsin and 
pancreatin : 

(1) It will convert or digest many more times its own weight 
of meat than they are able to do. 

(2) It can be used when pepsin and pancreatin are contra-indi- 
cated or powerless. This is the case when 



DISEASES OF THE DIGESTIVE SYSTEM. 379 

(a) The stomach contents being too highly concentrated, pepsin 
ceases to act. On the other hand, papoid acts energetically even when 
the specific gravity of the stomach contents reaches 1.030 or over. 

(b) When there is such a deficiency of hydrochloric acid in the 
stomach that pepsin is inactive. Pepsin, as we know, can act effi- 
ciently only in the presence of a certain quantity of acid. That is to 
say, that the inactive proenzyme requires a certain percentage of acid 
to convert it into an active ferment. Papoid, on the other hand, 
being independent of the presence of an acid, will do its work even 
under these conditions. 

(c) When the stomach's contents are so acid that, poured out 
into the duodenum, they inhibit the action of the pancreatin fer- 
ment. It not infrequently happens in cases of hyperacidity of the 
stomach that the intestinal juices are unable to neutralize the intensely 
acid chyme. As the pancreatic ferment can act only in the pres- 
ence of an alkali, duodenal digestion is at once arrested and various 
unpleasant symptoms supervene. It is obviously of no use to give 
pancreatin by the mouth, as it is at once destroyed by the acid in 
the stomach. And in these cases it is of no use to give an alkali 
with it, as is often done, as it would be practically impossible to give 
a sufficient dose to neutralize the contents of the stomach without 
damage to the organism. Papoid is here of the greatest use, as its 
activity is not affected by the contact with acid. 

(3) As regards albumenoids, it combines in itself the joint action 
of pepsin and pancreatin. 

(4) It can be combined with acids, alkalies, or antiseptics, as 
indicated by the demands of the case. 

(5) It has a local action on the stomach that pepsin has not. 

(a) It has a distinct tonic action on the secreting mechanism of 
the stomach, stimulating the secretion of the gastric juice. 

(b) It has a local sedative action, relieving pain in a marked 
degree, &nd this it does whether the pain is due to the presence of 
irritating ingesta, or is a local neuralgia. 

(c) It dissolves the unhealthy mucous coating of the interior of 
the stomach that interferes with the gastric secretions and the absorp- 
tion by the stomach walls. This condition is met with chiefly in the 
chronic stomach catarrhs of children, in cases of alcoholic dyspep- 
sia, and in most cases of chronic gastritis. 



380 THE PRACTICE OF MEDICINE. 

(d) It is distinctly antiseptic in its action. It thus prevents the 
abnormal fermentative processes from taking place in the stomach 
and intestines. An important point in its favor is that it can be 
given in conjunction with other antiseptics, when necessary, without 
its action being in any way interfered with. This is not the case 
with pepsin. 

(6) And last but not least, being purely vegetable, it is not so 
repulsive as pepsin. With animal ferments, prepared from stom- 
achs of pigs and other animals, there is always a possible doubt as 
to the freshness or healthy condition of the material. If at all 
tainted they may contain bacilli, ptomaines, and other toxic sub- 
stances, particularly as in preparing pepsin and pancreatin it is impos- 
sible to raise the temperature high enough to destroy these without 
rendering the ferment also inert. 

From a consideration of the foregoing we see that papoid is indi- 
cated in the following conditions : 

(1) Deficiency of the gastric juice from (a) atrophy of the gas- 
tric follicles ; (b) deficient blood supply. This occurs in anaemia and 
general debility. 

(2) Excess of unhealthy mucus in the stomach. This occurs in 
chronic gastric catarrh, chronic alcoholism, and in the chronic stom- 
ach catarrhs of children. 

(3) Irritable conditions of the stomach, associated with pains and 
vomiting. 

(4) Duodenal dyspepsia. When its local action is desired it is 
given on an empty stomach, and when it is administered for its 
digestive effect it may be given either with the food or shortly after. 
(Herschell's Manual.) 

Merck's "Juice of the Pawpaw," Wurtz's Papain or Papayotin, 
and Finkler's Papoid are said to be similar, but this has been dis- 
puted. An eminent chemical authority writes me that " Papayotin 
is a highly concentrated extract of the juice of the pawpaw, and that 
it cannot be used instead of papoid, or the dried pawpaw juice. It is 
said to be so corrosive as to prevent its use in large doses, and that 
it possesses widely different physiological effects." But Dr. Jacobi 
says papayotin is not caustic, and can be given in doses of five or ten 
grains, and does act in an acid or alkaline medium. Evidently there 
is still an uncertainty about the various preparations. 



DISEASES OF THE DIGESTIVE SYSTEM. 381 

Beef tea will often ferment in the stomach unless a little muri- 
atic acid is added to it. The juice of the pine-apple added to beef 
tea has the same effect as the acid. "Mosquera's Beef Meal" is 
predigested by the action of pine-apple juice. 

It has lately been discovered that Condurangu bark notably 
increases the gastric juice. The genuine bark is finely ground and 
given in doses of five to ten grains. It is said to equal bismuth in 
its sedative action on an irritable stomach. Columbo has long had 
a similar reputation. Muriate of hydrastine (white alkaloid) has 
the same sedative effect. Resorcin, cocaine, kava kava, and boldo 
are said to have a similar action. 

One of the best palliative remedies I ever used in the acid, fer- 
menting, painful dyspepsia of children or adults is the following : 

Glycerine, chloroform water, of each one ounce ; distilled water, 
two ounces; a teaspoonful every half -hour until the patient is 
relieved. To this may be added papoid, one drachm, when there is 
undigested food in the stomach or intestines. 

There are certain mineral springs having a deserved reputa- 
tion in chronic gastritis. They are all mild alkaline waters. Vichy 
(European or American); Saratoga waters, alkaline and mildly 
saline ; some of the sulpho-saline springs of this country ; Carlsbad 
in small quantities. But they should not be taken ad libitum, as 
patients are prone to do unless restricted. 

It is not always the water alone at watering places that cures. 
It is partly the change of air, new scenes, society, and exercise. 
But the best of water will do no good if the patient eats improper 
food, and too much of it, while at the springs. 

The principle derived from these mineral waters is not their lax- 
ative action. When properly used they dissolve and wash away the 
mucus which adheres to the stomach and intestines, preventing diges- 
tion and assimilation. 

Carlsbad (native or foreign) has the best reputation, but when 
used in excess will cause the very condition for which it is recom- 
mended. 

A small glass of the water, or a teaspoonful of the powdered 
salts in a glass of water, should be slowly sipped — hot — on rising 
in the morning before eating. In chronic cases this is repeated 
before each meal. For mild cases of gastric catarrh with acidity, 



382 THE PRACTICE OF MEDICINE. 

the alkaline waters suffice. In chronic cases the saline-alkaline 
waters are more efficient, such as the springs of French Lick, Indi- 
ana, and those near Enterprise, Florida, and similar springs in Ken- 
tucky, Virginia, and Pennsylvania. 



DILATATION OF THE STOMACH. 

This condition may occur from several causes. (1) Acute dila- 
tation from eating or drinking an enormous quantity at one time. 
Instances have occurred in which the stomach never recovered from 
the violent distension, and death has resulted from paralysis after 
excessive eating or drinking. (2) Narrowing of the pylorus or the 
duodenum by the cicatrization of an ulcer. Stenosis of the pylorus 
from hypertrophy, congenital stricture, a tumor, or floating kidney. 
(3) Relative or absolute insufficiency of muscular power of the stom- 
ach, due to repeated distension from over-filling, or atony of the 
coats induced by chronic gastritis, degeneration, etc. The most 
extreme form arises from stenosis of the pylorus, due to contraction 
as a sequence of ulceration. 

The same condition occurs in the stomach as in the heart. There 
may be considerable stenosis and but little dilatation owing to com- 
pensation-thickening of the muscular coats. This is a physiological 
cure in the stomach. When with chronic catarrh of the stomach 
there is habitual over -feeding and drinking, we are sure to find a 
tonic dilatation of the stomach. The employes of breweries, who are 
allowed thirty and forty glasses of beer daily, are generally victims 
of this condition ; an exclusive diet of milk has been known to cause 
it. It is most frequent in middle-aged and old persons, but may 
occur in children, especially in association with rickets. 

The most characteristic symptom, says Osier, is the vomiting at 
intervals of enormous quantities of liquid and food, amounting some- 
times to four or more litres (five or six quarts). The material is 
often of a dark grayish color, with a characteristic sour odor, due to 
the organic acids present, and contains mucus and remnants of food. 
On standing it separates into three layers, the lowest consisting of 
food, the middle of a turbid dark gray fluid, and the uppermost of 
a brownish froth. Microscopical examination shows a large variety 
of bacteria, yeast fungi, and the sarcinae ventriculi. There may be 



DISEASES OF THE DIGESTIVE SYSTEM. 383 

also present fruit stones and berry seeds. Owing to the small 
amount of fluid which passes from the stomach, there is constipation, 
scanty urine, and dry skin. There is malnutrition, emaciation, and 
extreme weakness. 

Kussmaul says tetanus may occur, the spasm affecting chiefly the 
muscles of the hands, arms, and legs. I have seen two cases of the 
kind attending simple dilatation. 

" On physical inspection the outline of the enlarged stomach may 
be plainly seen, the small curvature a couple of inches below the 
ensiform cartilage, and the greater curvature passing obliquely from 
the tenth rib on the left side toward the pubes, and then curving 
upward to the right costal margin. On palpation the resistance of 
a dilated stomach is peculiar, and has been compared to that of an 
air-cushion. There is a splashing sound which the patient can cause 
by depressing the diaphragm. 

" When on percussion in the standing posture the bottom line of 
resonance is even with the navel, or below it, dilatation of the stom- 
ach may generally be assumed to exist. 

" On ausculation a curious sizzling sound is present, not unlike 
that heard when the ear is placed over a soda-water bottle when first 
opened." (Osier.) On auscultating of the epigastric region in some 
patients for supposed heart disease, I have found the heart sounds 
transmitted with great clearness and with a metallic sound. In such 
cases the dilatation of the stomach was the cause of the cardiac dis- 
turbance. 

Treatment. — Dilatation from stenosis of the pylorus or duode- 
num cannot be cured, but may be alleviated by aiding compensa- 
tion. When dependent on simple atony, a careful regulation of 
the quality and of the quantity of food and drink may enable us 
to cure the patient. Medicines may further assist in the cure. The 
associated catarrh must be treated. Strychnine and nux vomica 
have been found the most useful of all drugs. They contract the 
fibres of the muscular coats of the stomach and bring about a nor- 
mal condition in simple dilatation, and aid compensation in stenosis 
of the pylorus. I have found the alternation of hydrastis, hydras- 
tine, or muriate of hydrastine with nux vomica or strychnine to give 
better results than any other medicinal treatment ; but in old cases 
these agents even aided by diet are insufficient, and we have to resort 



384 THE PRACTICE OF MEDICINE. 

to Kussmaul's method of emptying and washing out the stomach 
with warm water alone, or with some innocuous antiseptic solution. 
The patient can be taught to wash out his own stomach. Osier says 
he has known the practice to be followed daily for three years with 
great benefit. The rapid reduction in the size of the stomach is 
often remarkable ; the vomiting ceases, the food is taken readily, and 
in many cases the general nutrition increases rapidly. As a rule 
once a day is necessary, the first thing in the morning or the last 
thing before going to bed. In the morning there is usually a large 
amount of mucus (catarrhal) in a dilated stomach. This can be 
partially digested and loosened by taking two grains of papoid with a 
few grains of bicarbonate of soda, and sipping half a glass of hot 
water slowly before washing out the stomach. 

As there is more or less deficiency of gastric juice in such cases, 
pepsin or papoid with muriatic acid should be taken with the food. 

One of my patients who had tired of milk and buttermilk found 
malted milk very grateful and beneficial. 



NEUROSES OF THE STOMACH.— (Gastralgia, Gastrodynia.) 

This disease is sometimes called cardialgia, but this name should 
be adandoned. It is a disease of the stomach, consisting of severe 
paroxysmal pain in the epigastrium. 

It may occur (1) as a manifestation of a functional neurosis 
independent of any organic disease, and usually associated with other 
nervous symptoms ; (2) in chronic diseases of the nervous system 
forming the so-called gastric crises ; and (3) in organic diseases of 
the stomach, as ulcer or cancer. 

Drs. Salter and Clifford Allbutt relate cases which alternated 
with asthma, pseudo angina-pectoris, and enteralgia, and I have 
known it to alternate with ovarialgia ; others report cases where it 
alternated with hemicrania or megrim. 

Gastralgia often ceases suddenly, and in its place obstinate vomit- 
ing of food will occur. 

The symptoms are quite characteristic ; the patient is suddenly 
seized with agonizing pains in the epigastrium, which pass towards 
the back and around the lower ribs. The pain is described as 



DISEASES OF THE DIGESTIVE SYSTEM. 385 

cramping, constricting, twisting, cutting, shooting, darting, boring, 
aching, burning, and many other adjectives expressing violent forms 
of pain. Some will complain of a sensation as if ice or a cold stone 
lay in the stomach ; others of an intolerable sinking, faint, deathly 
feeling there, with an insatiable craving for spirits, and hot or cold 
drinks 

True cardialgia usually occurs independently of the taking of food ; 
it may occur at definite intervals, and be so periodical as to resemble 
the paroxysms of malaria. In fact it does occur during malarial 
attacks, and takes the place of the accustomed chill. It frequently 
comes on at night, waking the patient from sleep. Vomiting is rare ; 
more commonly the taking of food relieves the pain, but to this there 
are notable exceptions, as when a spoonful of any fluid or solid will 
terribly aggravate. Pressure may give relief, but deep pressure may 
be painful. During the paroxysm the pain may suddenly leave, and 
all the symptoms of an angina-pectoris set in, or it may be replaced 
by an enteralgia. I have known all the pains of a dysmenorrhea to 
leave suddenly and appear in the stomach. All these facts point to 
a constitutional or central neurosis. 

Treatment. — In this disease is shown the futility of trying to 
select a remedy from the local symptoms alone. Such a remedy may 
palliate, but rarely cures. It is like treating hysteria from the symp- 
toms alone, or like chasing a " will o' wisp." We must treat the 
constitution, or the neurosis, by remedies which are capable of caus- 
ing similar conditions. 

The palliative treatment in violent cases must consist of those 
agents that are distinctly anodyne. Patients will have immediate 
relief if possible, if this is not accorded them they doubt your ability 
to combat the disease. Hypodermic injections of codeine phosphate, 
one-fourth to one-half of a grain, generally affords quick relief. 
Morphine, or morphine with atropine, is also efficient. Chloroform 
by inhalation may be given if convulsions threaten ; a teaspoonful 
every ten minutes of chloroform water is often sufficient to relieve 
the pain. Hot applications externally and hot drinks are often 
of value. Cocaine, one-tenth to one-fourth of a grain, in cases 
marked by excessive hyperesthesia and vomiting has been used with 
benefit. 

Chamomilla, coffea, dioscorea, phosphate of magnesia, cocculus, 

25 



386 THE PRACTICE OF MEDICINE. 

ignatia, nux, and colocynth have often relieved the worst cases when 
closely affiliated. I have never known carbo vegetabilis in any dose 
to act as a palliative. 

The medicines most efficient for the removal of the local pain and 
the general neurotic state are nitrate of silver, asafcetida, arsenic, 
bismuth, aurum, cinchona or quinine, arsenite of quinine, arsenite of 
strychnine, nux vomica, ignatia, ferrum, hydrastis, phosphorus, Pul- 
satilla, sepia, picric acid, bromide of strontium, cyanide of zinc*, 
bromide of gold, sulphur, the hypophosphites, etc. 

The hygienic and climatic treatment is similar to that recom- 
mended for neursesthenia. 

Nervous Dyspepsia requires about the same medicines and hy- 
giene (see gastric neurasthenia). 

Peristallic Unrest. — Kussmaul was the first to describe this con- 
dition. Shortly after eating, or upon any emotion, the peristallic 
movements of the stomach and intestines are increased, and bor- 
borygmi and gurgling in the stomach and abdomen are heard by the 
patient and others, even at a distance. It is a part of the same 
hyperaesthetic condition of the nervous system as that in which a 
patient feels the normal beating of the heart. In some cases the 
movements of the intestines are distinctly felt, also the migration of 
the gases from one place to another. I have had patients so annoyed 
by the noises in the abdomen that they deserted society and public 
gatherings. I consider this condition similar to another still more 
distressing, in which soon after eating, or under any sudden emotion, 
the patient has an immediate desire for stool, which sometimes 
can be controlled, at other times not. A variety of this condition 
affects the urinary organs, when after drinking, or hearing running 
water, a desire to urinate, often very urgent, occurs. 

Treatment. — I have never found any remedy to cure this hyper- 
esthesia, although I have tried lycopodium, dioscorea, thuya, turpen- 
tine, phosphorus, nux moschata, and many others. In desperation 
some of my female patients have taken opium, a small dose, just 

* Probably no medicine yet known has such a decided curative action on 
combined gastric and cardiac neuroses as the cyanide of zinc. With it I have 
cured cases diagnosed as gastric ulcer, and others as angina-pectoris. In some 
cases the lx trituration is required; others are cured by the higher triturations. 
(See symptoms of stomach and hypochondrium of zinc.) 



DISEASES OF THE DIGESTIVE SYSTEM. 387 

"before going to a reception, with the result that the gurgling was 
temporarily arrested. The sympathetic or reflex nervous system is 
at fault, and its hypersensitiveness is a neuraesthenic state. I once 
thought that the bromides in doses sufficient to dull the reflexes 
would cure such cases, but I was disappointed. 

The true homeopathic remedies are such as will cause a similar 
hyperesthesia. Probably nux vomica, ignatia, and strychnine are 
the most appropriate medicines for the underlying conditions. Sum- 
bul, thuya, phosphorus, lycopodium, and salol may be useful. 



HEMORRHAGE FROM THE STOMACH. 

Haematemestis, or gastrorrhagia, may result from many condi- 
tions, some local, others general. 

The local causes are cancer, ulcer, miliary aneurisms, varicosis, 
acute congestion due to obstruction in the portal system ; and from 
hepatic, cardiac, or splenic diseases. 

The general causes are toxic : as the poison of specific fevers, 
yellow atrophy of the liver, purpura, phosphorus poisoning, traumat- 
ism from blows and wounds, corrosive poisons ; and constitutional 
diseases, as haemophilia, anaemia, malaria, and cholaemia. It may 
occur in hysteria and progressive paralysis of the insane. The blood 
may not come from the stomach, but flow into it ; it may come from 
the nose, pharynx, or lungs. It may come from rupture of an aneur- 
ism. I have known an infant vomit blood, and have found that it 
came from the breast of the mother. It may occur during the first 
two weeks of infant life and prove rapidly fatal ; the precise etiol- 
ogy of this form is not known. The two most common causes are 
undoubtedly ulcer of the stomach and cirrosis of the liver. 

Patients may die in profound syncope, without a drop of blood 
appearing externally. In such cases the stomach is distended with 
blood to the amount of three or four pounds. Sometimes it is diffi- 
cult to decide whether the fluid vomited is really blood. It may be 
the juice of red berries or wine. If the patient is taking iron or 
bismuth, the vomit will resemble a black coffee-ground mass, like 
blood altered in appearance by the gastric juice. Hysterical patients, 
or malingerers, will vomit fluids resembling blood, but which are 



388 



THE PRACTICE OF MEDICINE. 



really colored fluids they have swallowed for purposes of deception. 
In one such case, the girl being closely watched, it was found she 
chewed log-wood and swallowed the juice. 

For differential diagnosis compare the following parallel symp- 
toms : 

HEMOPTYSIS. 

1. Cough or signs of some pulmonary 
or cardiac disease precedes, in many 
cases, the hemorrhage 

2. The blood is coughed up, and is usu- 
ally preceded by a sensation of tick- 
ling in the throat. If vomiting oc- 
curs, it follows the coughing. 

3. The blood is frothy, bright red in 
color, alkaline in reaction. If clotted, 
rarely in such large coagula, and 
muco-pus may be mixed with it. 

4. The cough persists, physical signs of 
local disease in the chest may usu- 
ally be detected, and the sputa may 
be blood-stained for many days. 



HEMATEMESIS. 

1. Previous history points to gastric, 
hepatic, or splenic disease. 



2. The blood is brought up by vomit- 
ing, prior to which the patient may 
experience a feeling of giddiness or 
fainting. 

3. The blood is usually clotted, mixed 
with particles of food, and has an 
acid reaction. It may be dark, gru- 
mous, and fluid. 

4. Subsequent to the attack the patient 
passes tarry stools, and signs of dis- 
ease of the abdominal viscera may 
be detected. 



Bleeding from the stomach rarely proves fatal unless it comes 
from gastric ulcers, rupture of an aneurism, a varicose vein, or scir- 
rus of the liver. 

Treatment. — Our success in arresting the hemorrhage will de- 
pend on the accuracy of our diagnosis. If from ulcer of the stom- 
ach, arsenic, turpentine, sulphuric acid, erigeron, thaspium, nitrate of 
silver, bismuth, and resorcin. If from varicosis, ergot, hamamelis, 
carduus, collinsonia, hydrastis, millefoil, and sulphuric acid. If from 
obstruction in the portal system, mercurius, chelidonium, carduus, 
euonymin, aurum, phosphorus, and mercury. If from injuries, arnica, 
bellis, sulphuric acid, erigeron, and millefoil. If from splenic dis- 
ease, china, ceanothus, arnica, and arsenic. If from congestion, vera- 
trum viride, aconite, phenacetin, and aurum. If from cancer, bis- 
muth, charcoal, antipyrin, arsenic, and persulphate of iron. Ice 
pills, or small swallows of ice-cold water, have been known to arrest 
bleeding at the stomach. I have known hot water, so hot that none 
of the attendants could drink it, to arrest haematemesis when every 
other means had failed. 



DISEASES OF THE DIGESTIVE SYSTEM. 389 

ULCER OF THE STOMACH AND DUODEISTUM. 

Ulcers may occur in the stomach and in the duodenum. They 
are round, simple, and perforating, and probably follow some dis- 
turbance of nutrition in a limited area, which results in the gradual 
destruction of this area by the gastric juice. Hence the name, 
" peptic ulcer." It is usually attended by hyperacidity. 

Females are oftener affected than males. It is often associated 
with anaemia and chlorosis, and with menstrual disorders. The duo- 
denal is less common than gastric ulcer. It occurs in tuberculosis 
and may follow large superficial burns. It might be supposed that 
the ulcer would occur from traumatism or corrosive substances, but 
such is not the case. The disease is' said to be less common in this 
country than in Europe. There may be more than one ulcer ; cases 
have been reported where there were five, ten, and up to thirty. 
The ulcers are most commonly situated on the posterior wall of the 
pyloric portion at or near the lesser curvature. They may be small 
and punched out or reach an enormous size. If only the mucous 
coat is diseased the granulation tissue develops from the edges, and 
when healed over leaves a smooth scar. If the muscular coat is 
affected, contraction occurs. The ulcers may last for years without 
any attempt at healing ; they may deepen and penetrate all the coats, 
or adhesions may form between the stomach and pancreas, liver, or 
omentum. 

Fistulous communication may form into the colon, umbilicus, and 
even the pleura and pericardium. One of the most serious effects 
of gastric ulcer is erosion of blood-vessels ; the splenic artery may be 
perforated, or the artery supplying the eroded region may be plugged 
by an embolus. 

The symptoms in general are those met with in chronic dyspep- 
sia. Hemorrhage is present in nearly one-half the cases. It is gen- 
erally profuse and often in large quantities, and thrown up unal- 
tered ; this symptom is quite characteristic of ulcer of the stomach. 
In duodenal ulcer the blood may pass wholly into the intestines. 

Pain is the most constant and distinctive feature of ulcer. It 
may be only a gnawing or burning sensation, which is particularly 
felt when the stomach is empty and is relieved by taking food ; but 
more generally it appears in paroxysms of intense gastralgia, in which 



390 THE PRACTICE OF MEDICINE. 

the pain is not only felt in the epigastrium but radiates to the back 
and sides. These attacks are most frequent after taking food ; they 
occur at a variable period after eating, sometimes in fifteen minutes, 
or may not appear for two or three hours. The pain may occur 
at intervals with violence day after day for weeks, requiring power- 
ful anodynes ; then it will disappear for a long period. Why this 
should be has never been fully explained. During a paroxysm of 
pain the patient is usually bent forward, and is relieved by pressure 
on the epigastrium ; one leans over the back of a chair ; another 
lies flat on the floor with a hard substance under the abdomen. But 
while pressure is grateful during pain, it is not so in the intervals, 
when there is decided tenderness to the touch, and the patient can- 
not bear any tight clothing around the waist. There may be a very 
painful point of limited extent just below the ensiform cartilage, as 
in a patient now under my care. In old ulcers with thickening, a 
hard mass can be felt in the neighborhood of the pylorus. This 
lump I have found in several cases, and a post mortem verified the 
diagnosis. Stuart says the pain in ulcer of the stomach shoots 
through to the back, generally to the left. Winslow says the pain 
is often referred to the region of the spine corresponding to the last 
two or three dorsal and first two or three lumbar vertebrae, or to the 
interscapular region — the muscles on either side often being tender. 
(In five of my cases the pain alternated one day in the back, the 
next day in front, under the lower end of the sternum.) 

The pain may be at the umbilicus, and it has been known to radi- 
ate into the sides of the abdomen and up the oesophagus to the 
throat. These pains are often burning, boring, aching, shooting, or 
lancinating, with great soreness internally. 

Gall-stone colic simulates the pain of gastric ulcer, but the pain 
of the former stops suddenly, and the swelling of the liver, and jaun- 
dice, usually makes the diagnosis clear. 

Dr. Clifford Allbutt ("Visceral Neuroses") says : "The cases which 
simulate gastric ulcer are many. No doubt I have at times mistaken 
a case of ulcer for gastralgia, and at other times have assumed the 
existence of ulcer when gastralgia and gastralgic vomiting alone were 
present, but according to the correctness of our judgment must our 
treatment be helpful or hurtful, or positively mischievous. Possi- 
bilities do not help us much, for I think the ulcerous and pseudo- 



DISEASES OF IRE DIGESTIVE SYSTEM. 391 

ulcerous eases are about equally common." Dr. A 11 butt recom- 
mends arsenic and the salts of silver, and says he has cured some 
undoubted eases wirh them. His observations should make us very 
:.v. riaons in giving a diagnosis, especially in young neurotic women. 
Hysteria will imitate gastric ulcer perfectly, as I know from some 
mortifying experiences. 

Treatment. — If we are sure of our diagnosis, and the sufferings 
of the patient are severe, we should resort to the most decisive meas- 
ures 1 ^V"e should insist on an absolute rest in bed. (2) Rectal 
fee ling until the stomach has a period of inaction. < 3) ^Ynen 
we begin to feed by the mouth, as small an amount of food as is 
compatible with the maintainanee of life should be allowed: and it 
should be given in small quantities and at short intervals. Milk is 
the most suitable food, but not always can it be taken in its natural 
state. It can be shaken with lime water, or bismuth, or it may be 
frozen. I once treated an old man of sixty, who had an undeniable 
large ulcer of the stomach. After all other foods in various forms 
had been tried and he was nearing exhaustion, frozen milk was given, 
a tablespoonful every two hours. It caused no pain, and the amount 
was gradually increased until he took a teaeupful every two hours 
during the day. and occasionally at night, for six weeks, when he 
appeared so well that he was allowed scraped beef, and gradually 
other articles. He remained in good health for several years, finally 
dying of typhoid fever. A post mortem showed the cicatrix of a 
gastric ulcer on the posterior wall. The only medicine which relieved 
the paroxynis of pain in his case was codeine, which was given every 
day for three weeks, an average daily amount of three grains. 

Ice-cream has in many cases been the only food retained by the 
stomach. Two of my cases, women of twenty-five, lived on this food 
for several weeks, or until other food could be borne. It should be 
as free from sugar as possible and a little cornstarch can be added. 
New York ice-cream is the best kind in my experience, but any good 
home-made ice-cream will do. One of my patients could eat a par- 
ticularly delicate cake called •• angel's food " with the ice-cream ^but 
no other kind of cake or bread), and the ice-cold juice of water- 
melons. Milk gruels made with arrow root, farina, or some similar 
preparation, should be tried. Sometimes the essence of beef, mut- 
ton, or chicken asrrees when milk foods do not. Malted milk has 



392 THE PRACTICE OF MEDICINE. 

been satisfactorily used. Mosquera's beef meal or jelly are excel- 
lent. Luebe's beef solution, and Weyeth's or Valentine's beef juice 
in cold water is highly praised. Egg albumen may be used, but it 
should be only broken up, not be beaten to a froth. Buttermilk 
was well borne by some patients under my care. 

Hot food of any kind is never well borne in gastric ulcer. Hot 
tea or coffee should not be allowed, while in gastralgia neurosa they 
nearly always agree. Cold foods and drinks, even ice-cold, are 
nearly always best. When meats are allowed, only the juices should 
be swallowed. After a time tender scraped beef, delicate sweet- 
breads, or frogs' legs, can be tried, in small quantities at first. 

The medicinal treatment is uncertain, and useless unless the 
patient rigidly complies with our order of strict diet. The dominant 
school recommends nitrate of silver, bismuth, and opium. Ziemsen 
warmly recommends Carlsbad salts, a teaspoonful every morning, 
though few patients can take it, and if they can it only relieves the 
gastric catarrh without any specific action on the ulcer. In my 
cases Yichy was better tolerated than any other mineral water. All 
recommend opium for the pain, but I find codeine much the best. 
It requires from one-fourth to one-half of a grain at each dose. 
Osier recommends for the vomiting, cracked ice, oxalate of cerium, 
hydrocyanic acid, and ingluvin. For the hemorrhage he recommends 
opium and ergotin hypodermically. Ringer recommends turpentine, 
which I have found useful in one case (five drops every two hours), 
and in another, dilute sulphuric acid (five drops every two hours), 
I believe saved one patient's life. The only medicines homeopathic 
to gastric ulcer are nitrate of silver, arsenic, aurum, mercury, bichro- 
mate of potassium, phosphorus, stibium, and nitrate of uranium. 

Arsenic is the chief remedy. Its symptoms all correspond to 
ulcer of the stomach, especially when the ulcer is at the pylorus. If 
our triturations of the arsenious acids are prescribed, not lower than 
the 6th should be used. The arsenites of potassium and sodium can 
be given in the 3rd trituration or dilution. 

Aurum mur. is certainly indicated in erosion of the stomach if 
not in true ulceration. The red glazed tongue, pain in the pylorus, 
vomiting of food, and other symptoms point to severe lesions of the 
mucosa. If the symptoms of gold and arsenic seem mingled, give 
arsenite of gold, 3x trituration, before each meal, for it acts best 



DISEASES OF THE DIGESTIVE SYSTEM. 393 

when the stomach is empty. The symptoms and pathological lesions 
of bichromate of potassium indicate its usefulness in all round per- 
forating ulcers. It is recommended by Dr. Pope, of England, when 
the ulcer is at the cardiac end of the stomach. Lilienthal gives the 
special indications in full, the 3x to 6x being used. 

Dr. Blake's experiments with nitrate of uranium show it to have 
the specific power of ulcerating the pyloric mucous membrane in 
animals. Dr. Drysdale has shown it to be helpful in existing ulcer 
in man, and it may have the power to prevent ulceration. 

Nitrate of silver is indicated when there is pain below the zyphoid 
cartilage, in a small place extending to a corresponding point in the 
spine where pressure aggravates it. We use the 3x aqueous dilu- 
tion. Osier and Bristowe recommend one-fourth grain in four ounces 
of water, drank on an empty stomach. 

Subnitrate of bismuth is a favorite with all schools. It doubt- 
less has some specific curative, as well as profound sedative or pal- 
liative action. The severe pressing, burning pains, the sensation 
of weight and a load in the stomach, the intractable vomiting, all 
point out its value. If the drug is pure and free from arsenic the 
dose may range from one grain to thirty of the crude drug. I have 
frequently given one drachm before each meal, with no other than 
excellent results. Belladonna, atropine, conium, carbo vegetabilis, 
nux vomica, oxalate of serium, hydrocyanic acid, are only palliatives. 
An infusion of peach leaves often acts better than hydrocyanic acid. 
In one case great relief was obtained by eating a kernel of bitter 
almond before a meal. Dr. Habershon (" Diseases of the Stomach") 
recommends carbolic acid, one drop, or oxide of silver, one-fourth 
grain, and creosote, one drop, to relieve the pain and vomiting. 

Cundurangu bark is said by some German physicians to have an 
undoubted curative influence over gastric ulcer. Given in doses of 
three to five grains of the finely pulverized bark, it alleviates the 
pain, stops the vomiting of food, and the patients improve rapidly 
under its use. In cancer they found it useless. 

Muriate of hydrastia (white alkaloid), owing to its almost spe- 
cific influence over gastric catarrh, and its sedative influence upon 
the mucous coat of the stomach, may be of great assistance in the 
treatment of ulcer. I have no doubt cases occur in which mercurius 
corrosivus, phytolacca, sulphur, and barium may be of value. 



394 THE PRACTICE OF MEDICINE. 

CANCER OF THE STOMACH. 

It is said to be more frequent in England than in this country. 
Three-fourths of all cases occur between the ages of forty and sev- 
enty. It seems to be hereditary to a certain extent. Welch found 
a family history of cancer in 243 out of 1,744 cases. The stomach 
comes next to the uterus as the most frequent seat of primary cancer. 
Three varieties of gastric cancer are named : the encepholoid, scir- 
rous, and colloid. In 1,300 cases, 791 were in the pyloric region ; 
lesser curvature, 148 ; cardiac, 104 ; posterior wall, 68 ; anterior 
wall, 30. 

Most of the symptoms (subjective) of cancer of the stomach are 
similar to those of ulcer, but cancer of the stomach may not produce 
symptoms other than gradual failure of health, and death may take 
place from asthenia without any suspicion of the existence of malig- 
nant disease. 

There is a peculiar cachectic appearance of the patient with can- 
cer that we rarely see in ulcer. There is also an expression of the 
face, drawn, sad, and hopeless, which is also seen in cancer uteri. I 
believe I have been able to diagnose cancer of the stomach or uterus 
in many cases by this expression alone. 

In pernicious anaemia patients may have the cachectic appearance, 
but not the facial expression. Welch (" System of Medicine") gives 
an elaborate diagnostic comparison between cancer, ulcer, and catarrh 
of the stomach, but after reading it, one feels that the diagnosis is 
very uncertain. 

Treatment. — There is no special treatment and the disease is 
incurable. The same remedies recommended under ulcer should be 
used, for thereby we may be able to benefit the patient, even if we 
do not remove the cancer. 

There is a case of supposed scirrous of the stomach reported in 
" Therapeutics of New Remedies " in which hydrastis partially 
removed the tumor. (Dose, two drops morning and evening.) In 
the "North American Journal of Homeopathy," 1874, Dr. Freder- 
ick reported a case of corcinoma ventriculi, with co-affections of the 
epigastric and sub-clavicular lymphatic glands, cured by four drachms 
of the bark to half a pint of hot water, a tablespoonf ul twice a day. 
Dr. William Owens, of Cincinnati, values acetic acid highly in can- 



DISEASES OF THE DIGESTIVE SYSTEM. 395 

cer of the stomach. He says : " As a therapeutic agent acetic acid 
liquifies albuminous and fibrinous deposits as they are found in the 
various forms of hyperplasia?, indurations, and infiltrations, all the 
products of acute or chronic inflammation. It has proven particu- 
larly valuable in the treatment of epithelioma, cancerous affections 
and in the indurated chancre of primary syphilis. It is said to be 
the only agency that can liquify and disorganize the cancer cell. 

" Montgomery has demonstrated that it is capable of converting 
protagon into the round and spindle-shaped cancer cell. 

" In treating the cancerous patient we use locally the 2d dilution 
of acetic acid No. 8, and keep the part moist all the time, while we 
give internally the 1st dilution usually every four hours. The same 
course is pursued in treating epithelioma. In a few weeks exfolia- 
tion takes place, which continues until it leaves a healthy surface. 
Two cases of cancer of the stomach may here be referred to, both in 
well-known citizens. 

" Mrs. M., sixty-three years, had been under treatment for an 
affection of the stomach supposed to be cancerous, and had been so 
diagnosed by three physicians who were thought to be thoroughly 
competent. Every day she vomited partly digested food, sometimes 
mingled with blood. Had been constipated for about two months 
and had no stool for twenty-one days ; nodules as large as walnuts 
could be distinctly felt about the pylorus, and some degree of ten- 
derness extending across the stomach. The immediate occasion for 
my call to the case was the vomiting of a peculiar glairy gruel-like 
substance, mixed with partly digested food, mucus and slime, which 
the attending physician did not seem to understand. After a care- 
ful examination it was agreed that we probably had a case of cancer 
of the stomach or pylorus to deal with. Acetic acid, 1st dilution, 
w r as given every hour. There were two slight returns of the vomit- 
ing within the next two weeks. Improvement set in and continued. 
The dose was continued at longer intervals, and at the end of four 
months the patient was well and has so remained to the present time." 

"A second case, Mr. T., fifty-two years, had been under the med- 
ical charge, at different times for about two years, of three physi- 
cians, during which time more or less vomiting of undigested food 
had taken place, getting each month worse until about six weeks 
before I saw him. He then vomited each night all he had taken 



396 THE PRACTICE OF MEDICINE. 

the day before in a partly digested state, with mucus and slime. 
He had had no stool for two weeks previously, though the syringe 
had been used daily. Acetic acid, 1st dilution, was given every 
hour ; the syringe was used twice each day. In four months from 
the time he was seen, to a day, he walked out for the first time. 
There has been no indication of return of the trouble now nearly one 
year past." 

DISEASES OF THE INTESTINES. 
CATARRHAL ENTERITIS.— DIARRHCEA. 

There seems at present to be a concensus of opinion among path- 
ologists that the anatomical division of enteritis into duodenitis, jejun- 
itis, ileitis, typhilitis, colitis, and proctitis should be abandoned, for 
in the majority of cases the entire intestinal tract to a greater or less 
extent is involved ; sometimes the small intestine, sometimes the large 
bowel, but during life it is not always possible to say with any cer- 
tainty which portion is specially affected. 

The causes may be either primary or secondary. Among the pri- 
mary causes are: (1) Improper food, over-eating, especially of unripe 
fruit. In some persons certain articles of diet will cause diarrhoea, 
while the same articles never affect others. (2) Various toxines, 
such as the organic substances produced in the decomposition of milk, 
custard, and impure water ; or any change of drinking water ; drugs 
of various kinds ; changes in the weather, especially in the spring 
and fall when the temperature falls rapidly twenty or thirty degrees, 
or hot days and cool nights ; excessive heat of summer, especially in 
cases of children. A cold commencing as a coryza may travel the 
whole course of the digestive tract, causing catarrhal diarrhoea. (3) 
Increase of bile in the intestinal canal causes a diarrhoea termed 
bilious. Scanty secretion of the bile favoring fermentive processes, 
is a common cause of diarrhoea. Scanty pancreatic secretion has 
been supposed to cause the so-called " fatty diarrhoea," but Yierordt 
(" Medical Diagnosis ") says : " The increase of fat in the stool is 
not, as was formerly assumed, characteristic of a want of pancreatic 
juice (in disease of the pancreas) ; the absence of pancreatic juice 
does not seem to hinder the resorption of fat." He says the fat needles 
found in the stool may result from shutting off the bile from the intes- 



DISEASES OF THE DIGESTIVE SYSTEM. 397 

tines, from enteritis, and from disease of the mesenteric glands. (4) 
Nervous influences. In some neurotic persons any sudden or intense 
emotion may cause an increase of the peristaltic motions, and even 
increased secretion from the bowels. In children, it follows fright. In 
women, sudden joy or grief. In men, a telegram, or the news of a 
battle. During the civil war hundreds of soldiers were rendered 
non-combatants on the eve of a battle because of sudden prostrating 
diarrhoea. In hysterical persons this tendency may cause a veritable 
and obstinate chronic diarrhoea. 

Among the secondary causes are fevers, typhoid, bilious, and 
malarial ; dysentary, cholera, pyaemia, septicaemia, tuberculosis, and 
pneumonia ; chronic affections of the heart and lungs, liver and rec- 
tum, particularly a diseased condition of the pockets and papillae, or 
fissure and ulcer ; in the latter there is a continuous diarrhoea, pecul- 
iar and obstinate, which an operation only will cure. (See Diseases 
of the Rectum.) We also find diarrhoea in cancer, Addison's dis- 
ease, Bright's disease, and anaemia. 

Symptoms. — The stools may be of any color, and different shades 
of colors or of mixed colors. These colors are supposed to be influ- 
enced by the amount of bile mixed with the stools. A very dark 
green hue is supposed to indicate that it is mostly made up of bile, 
but the stools caused by mercury and some other drugs are very 
green, due to a chemical change ; and the grass-green stools, especially 
of children, may consist of altered blood, or may be due to a spe- 
cific micro-organism, as the microscope has shown. Pain is a general 
but not invariable symptom, and usually indicates an acute catarrhal 
condition, or the presence of food in the intestine. 

In attempting to make a diagnosis of the seat of the enteritis it 
may be noted that the stool from the small bowel usually contains 
portions of food, is more yellowish -green, or grayish -yellow, and 
flocculent, and does not contain mucus ; the diarrhoea is less marked, 
the pains colicky, and borborygmi infrequent. The large intestine, on 
the other hand, gives a stool of a uniform soupy consistence, greyish 
and granular throughout, with flakes or large quantities of mucus. 
There may be then no pain, or intense pain, with tenesmus. 

Treatment. — While I have every confidence in the curative 
power of medicines chosen according to the law of similia, auxiliary 
measures are at times imperative. If the diarrhoea is caused by indi- 



398 THE PRACTICE OF MEDICINE. 

gestible or toxic substances in the intestines, our remedies will not 
control it until they pass away. Nature alone cannot always remove 
them. We should aid by colon-flushings, laxatives of a non-irri- 
tating nature, like olive oil, castor oil, magnesia, Epsom salts, or 
congress water. After the foreign, irritating, or fermenting sub- 
stance is expelled, then the curative influence of medicine will 
promptly appear. We should also prohibit all solid or irritating 
food and drink, and give only such aliments as rice or barley water, 
arrow root, corn starch, or farina gruel, boiled milk and Vichy water 
equal parts, and demulcent beverages. 

I recommend " Bell on Diarrhoea " and McMichael's " Therapeu- 
tics of the Digestive System," as the best works we possess whereby 
to select the remedy. Not that I believe that all the symptoms are 
trustworthy, for I do not. I know that many are not due to the 
drug under which they are placed, and many of them are due to the 
coloring matter, or odor of the drug ; but for all that they are the 
best repertorial guides we now possess. In a work of this scope it 
is not expected that all the indicated medicines with their symptoms 
shall be given. 

In addition to the strictly homeopathic remedies for diarrhoea 
there are other methods, uncertain, though often curative of a diar- 
rhoea that has resisted the best selected proven medicines. Some of 
these belong to the class known to materia medica as " astringents." 
These agents have the power of contracting living tissues. When 
applied in moderate quantities to healthy mucous surfaces they con- 
tract the capillary blood-vessels and secretory glands, but if the dose 
is large, dilatation and relaxation follows. The text-books of the 
dominant school teach that astringents should not be used in conges- 
tion or inflammation of mucous surfaces, as they will aggravate, but 
that they are useful nevertheless in over-secretion with morbid dis- 
charges. 

In my " New Remedies " (fourth edition) I discussed this subject 
when writing of geranium maculatum, and I then asserted a doc- 
trine to which I still adhere, that astringents are primarily homeo- 
pathic to a mild form of congestion with dryness of mucous surfaces, 
a sub-acute inflammation ; and are secondarily homeopathic to relax- 
ation, i. e., the condition in passive hemorrhages, passive diarrhoea, 
and other discharges due to this relaxation. We have provings of 



DISEASES OF THE DIGESTIVE SYSTEM. 399 

very few genuine astringents : nitrate of silver, sulphuric acid, lead, 
alumen, bismuth, zinc, and copper among the minerals, but of no veg- 
etable astringents of any note. 

"We find sulphuric acid, bismuth, zinc, and copper very useful in 
chronic diarrhoeas. Tannic and gallic acid, of all astringents the 
most typical, are rarely useful in constipation or diarrhoea. This is 
a singular fact, while vegetable drugs which contain them are used 
successfully. I will not attempt to explain the parodox. 

Geranium maculatum is a typical vegetable astringent, but it con- 
tains other medicinal principles that may modify its astringent action. 
It contains nearly thirty per cent of tannin, but the tannin alone will 
not cure what the whole drug will. The same can be said of catechu, 
kino, haemytoxylon, rhatany, quercus, rhus glabra, blackberry root, 
rose leaves, and potentilla. Xow I have found that in many atonic 
or passive diarrhoeas these drugs act curatively, and in the most 
prompt and energetic manner. Geranium is the most efficient of 
all : a few drops of the tincture frequently repeated will cure chronic 
diarrhoea in a few days or weeks. 

Eubus villosus (blackberry) and rubus canadensis (dewberry) 
have a world-wide popular reputation for the cure of atonic diarrhoea. 
Only the root should be used, as the berries have no value, and are 
positively harmful. The " blackberry cordials ; " made from the juice 
of the berries are abominable frauds and should never be used. A 
good tincture of the roots in ten to twenty drop doses, or one to four 
drachms of the simple syrup, is the best preparation. TTith this 
■• blackberry syrup " I have cured atonic diarrhoeas of children when 
all other medicines failed. 

Potentilla, a wild fruitless species of the family Fragaria (straw- 
berry), is nearly equal to blackberry hi chronic colliquitive dis- 
charges from the bowels. The tincture or decoction of the leaves 
should be used. In Eussia, England, and in this country the leaves 
of the raspberry are valued highly in the same disease. 

All the roses possess the same properties. A recent Eussian 
writer praises very highly an infusion of the red rose as being the 
most potent remedy in the chronic diarrhoea of children. One 
drachm of the leaves is steeped in one ounce of boiling water, and 
a teaspoonful of this is given every hour ; I have found it useful 
in many cases. Some of the most obstinate cases I ever treated 






400 THE PRACTICE OF MEDICINE. 

were relieved by a few drops of tincture of kino three times a day. I 
can say the same of rhatany (krammeria), and haemytoxylon (log- 
wood). 

There is another class of medicines rarely used in diarrhoea that 
act in a manner peculiar to themselves. Coffea, guarana, kola, and 
thea all contain tannin, and all an alkaloid similar to caffeine. In 
persons who do not use coffee, a few drops of the tincture, or a tea- 
spoonful of a strong decoction will cure lientery — a diarrhoea of 
feculent undigested food. Guarana and kola will cure obstinate 
chronic cases in which the atony of the stomach and bowels is such 
that the food passes away partially digested. These two last medi- 
cines should never be lost sight of in chronic cases. 

There was once sold a beverage called " acorn cocoa," made of 
equal parts of roasted acorns and cocoa; this used as a drink in 
atonic diarrhoeas of children gave most excellent results. A bever- 
age of roasted sweet acorns with cream and sugar is quite as palata- 
ble and equally curative. 

Rhus glabra and rhus aromatica are both useful in chronic diar- 
rhoea and dysentery after the acute stage has passed, and the dis- 
charges are kept up by atony of the mucous membranes and mus- 
cular tissue of the intestines. The dose is ten to fifteen drops of 
the tincture several times a day. Headland ("Action of Medicines") 
says all astringents primarily contract muscular tissues and second- 
arily relax them. There are some chronic diarrhoeas which accord- 
ing to recent investigation appear to be caused, or continued, by cer- 
tain ferments due to fungi or bacteria. They have their seat in the 
large bowel. The evacuations are foamy, frothy, sour, and horribly 
offensive. The treatment of such cases should be partially or wholly 
conducted by the use of antiseptic agents. 

Among the most useful is naphthalin in doses of one-tenth of a 
grain to three grains, three times a day. It is especially useful 
when parasitic worms are present, or the bacillus typhosus. 

Benzo-naphthol is equally useful when fungi or poisonous bacteria 
are present. The dose is a few grains of the lx or 2x. The foetor 
of the stools are soon removed by its use. Salol in doses the same 
as naphthalin, is often more efficient and curative than either of the 
above ; salicylate of sodium often rivals salol, especially when bile is 
absent from the stools. Creosote has also been found of equal value. 



DISEASES OF THE DIGESTIVE SYSTEM. 401 



DIARRHOEA OF CHILDREN. 

Pathologists now divide this disorder into three forms : (1) acute 
dyspeptic diarrhoea ; (2) cholera infantum ; and (3) acute entero- 
colitis. 

I propose to discuss each separately, as the treatment of each is 
distinct. Infantile diarrhoea occurs most frequently in children arti- 
ficially fed. Of two thousand fatal cases only six were entirely breast- 
fed. It occurs between the ages of six and eighteen months. The 
relation of the temperature to the prevalence of diarrhoea is import- 
ant. The mortality curve begins to rise in May, and reaches the 
maximum in July, and then gradually declines until the end of Decem- 
ber. It is not much influenced by barometric pressure or humidity, 
but great heat and great humidity certainly increase the death-rate. 

The relation of bacteria to infantile diarrhoea is also important. 
The bacillus lactis aerogenes is only present in the intestines after a 
milk diet, milk sugar appearing to furnish the materials necessary 
for its growth. It lives in the upper portion of the bowel, and excites 
the fermentive processes in milk. The bacterium coli commune is 
found mostly in the lower intestine, and influences certain phases of 
digestion. These are not toxic. Only the bacteria of the proteus 
group are pathogenic. 

The morbid anatomy of these diarrhoeas is as follows : There is 
catarrhal swelling of the mucosa of the large and small intestines, 
with enlargement of the lymph-follicles. In chronic cases these lat- 
ter show small erosions or ulcers ; more rarely a croupous inflamma- 
tion affects the lower part of the ileum and colon. Brain lesions are 
rare, but the membranes and brain substance are often anaemic. 



ACUTE DYSPEPTIC DIARRHCEA. 

Symptoms. — The child, after being feverish and restless at night, 
has frequent stools containing undigested food and curds ; these are 
very offensive ; or vomiting, griping pains, and fever may suddenly 
occur, the temperature rising rapidly until it reaches 104° or 105°. 
There may be convulsions at the outset, or jerkings and twitchings 
at the slightest noise during sleep. The abdomen is sensitive ; the 
child does not like to be moved, and lies with legs drawn up. The 



26 



402 THE PRACTICE OF MEDICINE. 

stools consist of grayish or greenish yellow foeces mixed with curds, 
gas, and portions of food; they are rarely watery or serous. In 
children over two years of age these attacks follow the eating of un- 
ripe, or partially chewed food, or tainted milk. Under careful treat- 
ment this disturbance passes off in a few days, but relapses occur, 
or the attack may run into an entero-colitis. 

Treatment. — All solid food must be withheld, even sterilized milk, 
and the child placed upon a diet of cool rice or barley water. Some- 
times fresh milk and Yichy water, equal parts, may be given. If the 
attack has followed the use of undigestible food, it should be carried 
out of the bowels by enough magnesia, castor oil, or mercurius dulcis to 
have that effect. I prefer the milk of magnesia, or " Husband's mag- 
nesia." If the fever is high and the child is very nervous, aconite lx 
and belladonna 2x should be given until the temperature is lowered. 
Chamomilla is sometimes better than belladonna for the extreme re- 
flex erethism. Use ipecac lx if the vomiting is persistent, or bismuth 
(five grains every hour) if ipecac does not arrest it in a few hours. 
Give iris lx if there is sour vomiting, and sour diarrhoea of a pale 
lemon color with frequent small flatulent movements ; and Pulsatilla 
3x if there is much mucus in the vomit and stools. Rheum lx if the 
stools are feculent and sour. 

Senna, castor oilj aloe, podophyllum, china, colocynth, dioscorea, 
and dulcamara are also appropriate. For indications, consult Bell on 
" Diarrhoea " or McMichael's " Repertory." 

Many cases of this form will be attended by such severe convul- 
sions that chloroform will have to be given to arrest them ; or bro- 
mide of potassium or strontium every hour, one grain for each year 
of the child's age. Many prominent authorities now recommend irri- 
gation of the stomach and bowels during the early stages to remove 
decomposing matters in the stomach and intestines. This method is 
doubtless of value, but it can with difficulty be introduced into pri- 
vate practice. In hospitals for children it can be practiced because 
there is no parental interference. 

A large-sized soft rubber catheter is introduced into the stomach, 
and by means of a funnel, lukewarm water can be made to pass in 
and out until it becomes quite clear. Irrigation of the large bowel 
can be managed as follows : the child should be placed on the back 
with the hips elevated. A flexible catheter is pushed up six or eight 



DISEASES OF THE DIGESTIVE SYSTEM. 403 

inches, and one or two pints of warm water allowed to flow in from 
a fountain syringe. I have not practiced irrigation of the stomach, 
but have irrigated the colon in several cases of horribly offensive diar- 
rhoea, with excellent results. In one instance I added resorcin, one 
drachm, to a pint of glycerine and water. It brought away old fae- 
cal masses and disinfected the intestine. Recovery rapidly followed. 
In several cases of obstinate enter o- colitis (called dysentery) two 
drachms of paregoric in a pint of water thus injected effectually and 
safely arrested the disease. 

The hygienic management and dietetic treatment of children suf- 
fering from chronic infantile diarrhoea is equally if not of more 
importance than the medicinal. 

" The effect of a change from the hot stifling atmosphere of a 
town to the mountains or sea is often seen at once in a reduction in 
the number of stools and a rapid improvement in the physical condi- 
tion. Even in the cities much may be done by sending the child 
into the parks, or for daily excursions on the water. However 
extreme the condition, fresh air is indicated. The child should not 
be too thickly clad. Many mothers, even in warm weather, clothe 
their children too heavily. Bathing is of value in infantile diar- 
rhoea, and when the fever rises above 102° or 105° the child should 
be placed in a warm bath, the temperature of which may be grad- 
ually reduced, and by keeping the child in the bath for twenty min- 
utes, the water will at the end of that time be sufficiently cooled. 
Much relief is obtained by the application of cold wet cloths, or in 
rare cases of unusual severity the ice-cap to the head. Irrigation of 
the colon with cold water is sometimes favorable, but it has not the 
advantage of the general bath, the beneficial effect of which is seen, 
not only in the reduction of the temperature, but in a general stimu- 
lation of the nervous system of the child." (Osier.) 

Dietetic Treatment. — " In the case of a hand-fed child it is im- 
portant, if possible, to get a wet nurse. While fever is present, diges- 
tion is sure to be much disturbed, and the amount of food should be 
restricted. If water or barley water be given, the child will not 
feel the deprivation of food so much. When the vomiting is inces- 
sant it is much better not to attempt to give milk or other articles 
of food, but to let the child take water whenever it will. In the 
dyspeptic diarrhoeas of infants, practically the whole treatment is a 



404 THE PRACTICE OF MEDICINE. 

matter of artificial feeding, and there is no subject in medicine on 
which it is more difficult to lay down satisfactory rules. No doubt 
within a few years the study of the bacterial processes going on in 
the intestines of the child will give us most important suggestions. 
From his observations, Escherich lays down the following rules, 
recognizing two well-defined forms of intestinal fermentation, the 
acid and the alkaline. If there is much decomposition, with foul 
offensive stools, the albuminous articles should be withheld from the 
diet and the carbo-hydrates given, such as dextrin foods, sugar, and 
milk, which, on account of its sugar, ranks with the carbo-hydrates. 
If there is acid fermentation, with sour but not foetid stools, an albu- 
minous diet is given, such as broths and egg albumen. It is, how- 
ever, by no means certain whether the reaction of the stools, upon 
which this author relies, is a sufficient test of the nature of the intes- 
tinal fermentation. In the dyspeptic diarrhoeas of artificially-fed 
infants it is best, as a rule, to withhold milk, and to feed the child, 
for the time at least, on egg albumen, broths, and beef juices. To 
prepare the egg albumen, the whites of two or three eggs may be 
stirred into a pint of water, and a teaspoonful of brandy and a 
little salt mixed with it. The child will usually take this freely, and 
it is both stimulating and nourishing. It is sometimes remarkable 
with what rapidity a child that has been fed on artificial food and 
milk will pick up and improve on this diet alone. Beef juice is 
obtained by pressing with a lemon-squeezer fresh steak, previously 
minced, and either uncooked or slightly broiled. This may be given 
alternately with the egg albumen, or it may be given alone. Valen- 
tine's beef juice can be used when it is impossible to prepare the 
above. 

Mutton or chicken broth will be found equally serviceable, but it 
is prepared with greater difficulty, and contains more fat. In the 
preparation, a pound of mutton, chicken, or beef, carefully freed 
from fat, is minced and placed in a pint of cold water and allowed 
to stand in a glass jar on ice for three or four hours. It should 
be cooked over a slow fire for at least three hours, then strained, 
allowed to cool, the fat skimmed off, sufficient salt added, and it may 
then be given either warm or cold. These naturally prepared albu- 
men foods are very much to be preferred to the various artificial sub- 
stances. There is no form of nourishment so readily assimilated, 



DISEASES OF THE DIGESTIVE SYSTEM. 405 

and so little apt to cause disturbance, as egg albumen or the simple 
beef juices. The child should be fed every two hours, and in the 
intervals water may be freely given. It cannot be expected that, 
with the digestion seriously impaired, as much food can be taken as 
in health, and in many instances we see the diarrhoea aggravated by 
persistent overfeeding. When the child's stomach is quieted and 
the diarrhoea checked, there may be a gradual return to the milk diet. 
The milk should be sterilized, and in institutions and cities so sim- 
ple a prophylactic measure is of the very first importance, and is 
readily carried out by means of the steam sterilizer. The milk should 
be at first freely diluted, — four parts of water to one of milk, which 
is perhaps the preferable way, — or it may be peptonized. The 
stools should be examined daily, as important indications may be 
obtained from them. Milk whey and fermented milk are some- 
times useful, and may be employed when the stomach is very irri- 
table. 

In some instances " malted milk " will agree with the child better 
than any other food. It should be given at first very dilute, grad- 
ually adding more as the child improves. A mixture of one part 
pure cream to five parts water, or barley water, will be well borne 
when milk and barley water disagrees. 

Sterilized milk is not always beneficial. The fashion of steriliz- 
ing milk by subjecting it to a temperature of 212° for twenty or 
thirty minutes, and advising it in all cases of illness, especially in 
children, has had its day. After an experience of six years with 
milk so prepared I join in the verdict of the more practical members 
of the profession that while milk thus sterilized is useful in some cases 
of gastro-intestinal disorders, it is often very unsatisfactory when 
used as a regular food. In fact, I have known many children lose 
weight constantly under its exclusive use. 



CHOLERA INFANTUM. 

This disease in the infant is similar to cholera morbus or choler- 
aic diarrhoea in the adult. It is not so common as the form of infan- 
tile diarrhoea above mentioned ; occurring only in two or three per 
cent of the cases of summer diarrhoea. 

It prevails during hot weather and selects children artificially fed. 



406 THE PRACTICE OF MEDICINE. 

The main symptoms are uncontrollable vomiting, diarrhoea, and col- 
lapse. The vomiting is excited by any attempt to take food or drink. 
The stools are profuse and frequent ; at first faecal, brown, or yellow ; 
finally thin, serous, and watery. Like the vomiting, the stools fol- 
low immediately the swallowing of any liquid or solid. 

The first stools are very offensive, subsequently they are odorless. 
The thin, serous stools are alkaline ; there is fever, but the thermom- 
eter should not be placed in the axilla, for the temperature there is 
three or four degrees below that of the rectum. The thirst is insa- 
tiable ; the pulse rapid and feeble, and towards the end irregular and 
imperceptible. The eyes are sunken, the features pinched, the fon- 
tanelle depressed, and the skin is cold with a peculiar ashen hue. 
The tongue, coated at first, becomes red and dry. Death may occur 
within twenty-four hours, and with collapse there is very high inter- 
nal temperature. 

A singularly deceptive improvement sometimes occurs a few hours 
before the end ; when the vomiting and purging cease, and the child 
lies quiet ; but this apparent improvement is soon followed by coma 
or convulsions. In other cases the " hydrocephaloid state " described 
by Marshall Hall sets in, and imitates true hydrocephalus acutus. 

When the brain is examined after death no change is observed 
except anaemia of the meninges and substance. 

Dr. Osier believes this condition is probably caused by toxic 
agents absorbed from the intestine. No constant bacterial organism 
has been found, but Baginski considers the disease caused by the 
product of decomposition, brought about by various bacteria. 

Some very curious notions have been held concerning the nature 
of cholera infantum. It has been supposed to be a cerebral disease 
from the first, and a few of our school have asserted that belladonna 
would cure all cases " if given high enough." This is of course too 
absurd to be considered for a moment. Its nature is similar to that 
of true cholera without the contagious comma bacillus. 

Eational homeopathic treatment is far superior to that of any 
other school, yet the mortality under our treatment is fearful. There 
is no disease that requires such intelligent patient nursing, and such 
constant watching by the physician. 

During the first stage, if we are called soon enough the best rem- 
edy is mercurius dulcis lx ; a grain every hour, alternated with aco- 



DISEASES OF THE DIGESTIVE SYSTEM. 407 

nite lx, if the rectal temperature is high, 103° to 105°. When the 
stools become watery and serous, and prostration sets in, arsenite of 
copper 2x is generally the best remedy. It is indicated by the intense 
thirst, great restlessness, violent vomiting, cramps, and tendency to 
convulsions. A tablet can be partially dissolved and placed on the 
tongue, and after a few minutes a spoonful of ice-water given. Give 
the child cold water or very hot water (I prefer the latter), as much 
as desired, even if it is vomited ; but no food, liquid or solid, should 
be given until the dangerous symptoms subside. 

Camphor is sometimes useful, as in Asiatic cholera, when there 
is from the first collapse with coldness and blueness of the skin ; a 
drop of the lx in a spoonful of ice-water every fifteen minutes. In 
milder cases I have seen good results from the monobromide of cam- 
phor lx or 2x ; a grain every half -hour. 

Veratrum album is a potent remedy in many cases when its symp- 
toms are present. It has not the anxiety of arsenic, but the thirst 
is more insatiable, and internal cramps more noticeable. The stools 
are more watery, like rice water, and more profuse. I prefer the 3x 
dilution frequently repeated. No drug produces a more complete pic- 
ture of cholera infantum than ricinus communis (castor oil seeds), as 
pointed out in my " New Remedies." It has been used successfully by 
East Indian physicians in this disease, as well as in cholera asiatica 
— in the 6x dilution. 

There are cases of a mixed type that call for iris versicolor, cro- 
ton oil, gambogia, elaterium, gratiola, secale, and a few others. (See 
Bell on "Diarrhoea.") The use of any preparation of opium is 
highly reprehensible and always injurious. In the collapse, brandy 
in small doses may aid in bringing about reaction, but the hypoder- 
mic use of brandy and ether is cruel and the height of folly. Ice- 
cold champagne has been used with alleged benefit. 

During convalescence great care must be exercised to avoid 
relapses or entero-colitis. The first food given should be teaspoon- 
f ul doses of egg albumen or any suitable beef juice, and ten to fif- 
teen drops of this in a spoonful of cold water is often retained better 
than any other food. Milk should not be given for several days, 
and must be thoroughly shaken, peptonized, or mixed with arrow- 
root gruel, rice water, or barley water, equal parts. Later, a tea- 
spoonful of finely scraped raw meat is often well borne. 



408 THE PRACTICE OF MEDICINE. 

APPENDICITIS — (Typhlitis, Perityphlitis, Paratyphlitis). 

This is one of the most important of all intestinal affections. 
Osier says, " The use of the last two terms should be altogether dis- 
carded." Robson says, " All the forms of inflammation occurring in 
the neighborhood of the caecum should be discussed under the name 
of appendicitis." Both authorities teach that inflammation of the 
vermiform appendix is the cause of ninety per cent of all cases of 
this form of peritonitis. 

Osier divides the disease as follows : 

Typhlitis, inflammation of the caecum proper, is a doubtful and 
uncertain malady, the pathology of which is unknown, but which clin- 
ically is still recognized by authorities. A majority of the cases are 
unquestionably due to appendix disease. 

Appendicitis is : (1) catarrhal, (2) ulcerative, (3) perforative, 
with production of abscesses, which may be pericaecal, pelvic, intra- 
peritoneal, perinephritic or lumbar, depending on the situation of 
the vermiform process. 

Robson classifies as follows : (1) appendicitis without suppura- 
tion, depending on ulceration or catarrh, and producing local peri- 
tonitis, which has a tendency to resolution but which is liable to recur ; 
(2) perforating appendicitis, ending in suppuration, and producing 
either a local abscess or diffuse peritonitis. 

Typhlitis. — This disease is usually met with in young persons, 
in boys more commonly than girls ; the subjects have probably been 
constipated, and there have been errors in diet, or a resort to such 
purgative medicines as rhubarb, which leaves obstinate constipation 
as a secondary effect. The patient complains of pain in the right 
iliac fossa, and sometimes following the course of the colon. In chil- 
dren, according to Eustace Smith, it occurs between the ages of four 
and twelve. (The disease described by Smith in " Diseases of Chil- 
dren " as perityphlitis, is described by Osier and others as appendi- 
citis.) There is generally constipation, but in two of my cases the 
disease commenced with a diarrhoea. Vomiting of watery and bilious 
matter, or severe and distressing retching, may attend it. The tem- 
perature marks 101° or 102°. There is fullness in the right iliac 
fossa, the patient lies on the back, generally with the right thigh 
flexed, and any attempt to straighten it causes pain. On pressure 



DISEASES OF THE DIGESTIVE SYSTEM. 409 

there is tenderness, and in many instances a doughy, sausage-shaped 
swelling is found in the right flank. Percussion over this swelling 
yields a dull sound. 

In children these attacks are doubtless mistaken for " colic," but 
if the thermometer is placed in the rectum, and records 100° to 102°, 
typhlitis is present. The disease lasts from three to ten days, but 
is liable to recur from any error in diet, or if the bowels become 
constipated. 

Few writers mention any bladder complication, but in several of my 
cases the dysuria was terrible ; in others retention of urine occurred, 
necessitating a frequent use of the catheter. I have observed in sev- 
eral instances a recurrence of the attacks at the same time every 
year, usually in the winter. Many after recovery have attacks of pain 
in the caecum, lasting a day or two but unattended by swelling, the 
pain probably being due to incarcerated flatus in that region. 

Among the sequela? of typhlitis are continued tenderness of the 
iliac region and sciatica. No author whom I have consulted men- 
tions the latter, but I have observed it in several cases, one of which 
was my own. At the age of eighteen I became constipated, and to 
relieve it took every night for weeks a few grains of rhubarb root, 
which I had to increase continually. Being ignorant of its second- 
ary effects, its use was continued until hard faecal masses accumu- 
lated in the caecum. I was attacked with typhlitis, then called inflam- 
mation of the bowels. I was very ill for several weeks. The swell- 
ing of the caecum did not disappear for some time after I was able 
to sit up. During convalescence a severe right sciatica occurred 
which has followed me through life, gradually growing less severe 
since the age of sixty. 

Treatment. — Cowperthwaite, in Arndt's "System of Medicine," 
recommends belladonna, bryonia, hepar sulph., mercurius, and rhus 
tox. Lilienthal in addition recommends opium, plumbum, lache- 
sis, and others. My experience convinces me that of all these, only 
belladonna and mercurius are of any value. The symptoms given 
under bryonia and rhus are rheumatic and have no relation to typh- 
litis. 

Opium and plumbum may be of use in the old " typhlitis stercor- 
als," but not for the disease now under consideration. 

When I am sure I have a case of typhlitis I give belladonna lx 



410 THE PRACTICE OF MEDICINE. 

or the tincture twenty drops in four ounces of water, a teaspoonful 
every half-hour. After twelve hours I give mercurius dulcis 2x 
(five grains), in alternation with belladonna, two or four hours apart, 
all through the disease, or until decided improvement sets in. For 
the relief of the severe pain dioscorea tincture, ten drops every 
half-hour, is better than any other drug. Colocynth is not often 
indicated. If any anodyne must be used, codeine is to be preferred 
to any other preparation from opium, as it does not constipate or 
derange the stomach. Give one-third to one-half of a grain, hypo- 
dermatically or by the mouth, every two or four hours if necessary. 
When there is a large swelling in the iliac region I give phytolacca 
in place of belladonna. I have always used hot applications, gener- 
ally a poultice of flaxseed meal with a little turpentine and aconite 
or opium in it. Like Cowperthwaite I have not found ice bags 
agreeable to the patient, nor has it given the relief which Bartholow 
or Osier claims for it. 

In the beginning I order an enema of warm water thrown into 
the colon by means of a long flexible rectal tube, two quarts for 
an adult, and one pint for a child. Instead of soap I prefer glycer- 
ine, adding an ounce to each pint of fluid. I have found that these 
enemata soften and dissolve the faecal accumulations. They should 
be used twice a day until the colon is empty clear to the csecal valve. 
I believe the disease can thus be greatly shortened and deprived of 
its danger. 

In this disease it is important that the colon should be rendered 
antiseptic. No other drug than salol accomplishes this so thoroughly. 
Three or five grains in pill or capsule can be given every six hours. 
It not only acts as an antiseptic but has I believe a curative influ- 
ence over the inflammation. It reaches the colon before it is dis- 
solved, and acts on the mucous surfaces as an anodyne. 

Appendicitis. — As before remarked the concensus of present 
medical opinion is that inflammation of the appendix vermiformis is 
at the bottom of nearly all the diseases known as typhlitis and peri- 
typhlitis. 

For a proper understanding of appendicitis and its symptoms, the 
anatomical relations should be considered, else we shall be at a loss 
to account for the concomitant symptoms. As Osier gives the clear- 
est statement I quote his observations : 



DISEASES OF THE DIGESTIVE SYSTEM. 411 

" The appendix vermiformis is extremely variable in position. It 
commonly lies behind the ileum with the tip pointing toward the 
spleen. It is frequently turned up behind the caecum, or it lies upon 
the psoas muscle with its tip at the margin of the pelvis. It has, 
however, been found in almost every region of the abdomen. Thus 
in my post-mortem notes it is stated to have been found in close con- 
tact with the bladder ; adherent to the ovary or broad ligament ; in 
the central position of the abdomen, close to the navel ; in contact 
with the gall-bladder ; passing out at right angles and adherent to the 
sigmoid flexure to the left of the middle line of the abdomen ; and 
in one case it passed with the caecum into the inguinal canal, curved 
upon itself, re-entered the abdomen, and was adherent to the wall of 
an abscess cavity just to the right of the promontory of the sacrum. 

" Foreign bodies rarely lodge in it. Only two instances have come 
under my notice ; in one there were eight snipe-shot, and in the 
other five apple pips. On the other hand, oval bodies resembling 
date-stones are very common. They consist of inspissated mucus 
and faeces, in which in time, lime salts are deposited, forming entero- 
liths. 

" Post-mortem examinations show that the appendix is very fre- 
quently the seat of extensive disease, past or present, without the 
history of any definite symptoms pointing to trouble in the caecal 
region. Among the commonest of these conditions is obliteration, 
either total or partial. When at the caecal end, the appendix may 
be enormously dilated, forming a tumor the size of the thumb or as 
large as a sausage. In the case of obliteration the appendix may be 
free ; more commonly it is adherent, and there may be about it signs 
of old inflammation, or even a small encapsulated abscess, which has 
given no trouble." 

Etiology. — Appendicitis is a disease of young persons. Accord- 
ing to Fitz's statistics, more than fifty per cent of the cases occur 
before the twentieth year ; sixty per cent between the sixteenth and 
thirtieth years. It has been met with as early as the seventh week, 
but it is rarely seen prior to the third year. It is very much more 
common in males than in females, eighty per cent, according to the 
tables of Fitz, but in his personal experience in seventy-two cases 
males were only twice as frequently affected as females. Contrary 
to the general experience, the Munich figures (Einhorn) indicate 



412 THE PRACTICE OF MEDICINE. 

a relatively greater number of women attacked. The faecal concre- 
tions and foreign bodies already referred to probably play the most 
important role in the etiology of the disease. In a series of 152 
cases the faecal masses were present in forty-seven per cent and for- 
eign bodies in twelve per cent. Matterstock, in 169 cases of per- 
forative appendicitis, found the percentage to be fifty-three and 
twelve, respectively. Typhoid fever and tuberculosis frequently 
induce ulceration of the appendix, but not often perforation. Fitz 
suggests that some of the cases of peritonitis which recover in typhoid 
fever are due to the perforation of the appendix. Traumatism 
plays a very definite role, and in a number of cases the symptoms 
have followed the lifting of a heavy weight, or a fall, or a blow. 
Constipation, overloading the stomach with indigestible food, indis- 
cretions in diet, are mentioned in many cases. The tendency of the 
disease to recur is remarkable. Among 257 cases (Fitz) eleven per 
cent had had previous attacks. In the recurring appendicitis, no 
factor is of greater importance than overeating, and attacks may fol- 
low directly upon the taking of large quantities of unsuitable food. 

Modern authorities recognize two forms of this disease. (1) 
Catarrhal inflammation, in which the entire tube is thickened, the 
peritoneal surface injected and perhaps adhesions formed, showing 
that there has been slight peritonitis. The mucous lining is thick- 
ened and covered with tenacious mucus, and very commonly faecal 
concretions and small enteroliths are present. All the coats are 
thickened, especially the muscular, and the entire tube may be firm 
and stiff. It may attain the size of the index finger or thumb. 
When opened it rolls outwardly, showing the interior surfaces. (2) 
Perforation and ulceration. Dangerous ulcers are caused by the irri- 
tation of faecal concretions or foreign bodies, such as seeds, stones, and 
hulls of grain. Typhoid fever and tuberculosis may cause ulceration. 

Perforation may arise from obliteration of the caecal end, dis- 
tending the lumen with fluid. When perforation occurs it may at 
once excite violent and diffuse suppurative peritonitis, but more 
commonly adhesion takes place and a local peritonitis results. 

When abscesses occur they may be located at various places, 
most commonly on the psoas muscle near the terminal portion of the 
ileum. It may be within the pelvis close to the ileum, or between 
the ileum and sacrum. In some cases a large circumscribed abscess 



DISEASES OF THE DIGESTIVE SYSTEM. 413 

forms in the iliac region and points midway between the umbilicus 
and the anterior superior spine of the ilium. Wherever the abscess 
locates it excites severe peritonitis, even if the abscess does not rup- 
ture. 

When the appendix is not within the peritoneum, perforation 
produces a retroperitoneal abscess, and the pus may burrow and 
appear at Poupart's ligament, discharging outwardly, and recovery 
may follow. The pus may form a large perinephritic abscess, and 
perforate the diaphragm and pleura. It may extend along the psoas 
muscles and perforate the hip joint, or pass along the rectum, pro- 
ducing abscesses in the scrotum, or form a gluteal abscess. It may 
perforate the bladder or bowel, and be discharged through the rec- 
tum. It may burst into the veins, causing septicaemia ; or into an 
artery, producing dangerous hemorrhages. Many " psoas abscesses " 
are probably nearly due to disease of the appendix, and unless there 
is unmistakable evidence of Pott's disease of the vertebrae such must 
be the origin. 

The symptoms of appendicitis are mainly of circumscribed peri- 
tonitis in the right iliac region, and such as were mentioned under 
typhlitis. 

Catarrhal appendicitis may occur without ulceration or perfora- 
tion. This form is not usually attended by constipation, in fact a 
diarrhoea may be present from the beginning. Resolution may take 
place without severe symptoms, but the attacks recur from time to 
time. 

Perforative appendicitis is a much more serious affair. The most 
unmistakable symptom is a sudden violent pain in the abdomen, 
usually in the right iliac fossa. It occurs in eighty-four per cent of 
all cases. This sudden, excruciating pain is not always confined to 
the fossa, but may extend to the navel, perineum, testicle, or thigh. 
An initial chill is rare, but fever, furred tongue, and vomiting may 
precede or accompany the pain. The temperature ranges from 101° 
to 103° or higher. The patient in walking bends over towards the 
right side, and cannot stand erect without pain. He lies on the back 
with the right leg drawn up, and cannot extend it without suffering. 
There may be fever, dysuria, or retention of urine. In children 
diarrhoea is more frequent than in adults. 

In some cases tympanites appears early ; in others the abdomen 



414 THE PRACTICE OF MEDICINE. 

may be hard, flat, and rigid as a board, even when there is diffuse 
peritonitis. The tenderness is generally located in the region of 
the appendix. A valuable diagnostic sign, first pointed out by 
McBurney, is " a point of tenderness on deep pressure situated 
from one and a half to two inches from the anterior superior spine 
of the ileum, on a line drawn from this point to the navel." In 
several instances I had observed this symptom before I saw McBur- 
ney's observation. Deep pressure causes agonizing pain at this 
point. The location of the swelling is various. It is sometimes an 
inch or two above Poupart's ligament ; it may be a diffuse thicken- 
ing and induration covering considerable space, or a well-defined 
tumor-like mass may be felt. If the abscess is large, fluctuation 
may be felt above Poupart's ligament or in the flank, but it can 
rarely be detected, because it is masked by the distended intestines. 
In two cases I have felt fluctuation in the rectum. 

Appendicitis may be mistaken for intussusseption, strangulation, 
or obstruction of the bowel. In women diseases of the tubes and 
pelvic peritonitis may simulate it. 

Appendicitis is one of the most serious and fatal of the abdom- 
inal diseases, yet post-mortem observations show that many cases 
recover, often without treatment. Recurrences are common, over 
forty per cent ; sixty-eight per cent of the fatal cases die during the 
first eight days. If the inflammation extends to the whole perito- 
neum it is almost always fatal. Perforation externally is generally 
followed by recovery ; if into the bowel it is more serious. 

Treatment. — The same medicines and local applications recom- 
mended as for typhlitis. Absolute rest is essential; the patient 
should not be allowed to stand, walk, or turn over in bed. The urine 
should be drawn by a catheter unless a bed-pan or urinal can be used, 
and a bed-pan should always be used to receive the evacuations from 
the bowels. 

Saline laxatives have been recommended, but Osier protests 
against their use, " because they have been advocated under a total 
misapprehension." They cannot benefit this disease, although they 
may be of benefit in typhlitis, but as it is rarely possible to make a 
diagnosis of the latter from appendicitis, it is best not to use them at 
all. In pelvic peritonitis and inflammation of the tubes, saline lax- 
atives are useful, but we should be sure of our diagnosis. 



DISEASES OF THE DIGESTIVE SYSTEM. 415 

Our school generally condemns opium in peritonitis and other 
inflammatory diseases of the bowels, but I am sure the condemnation 
should not extend to the disease under consideration. After we have 
unloaded the bowel with an enema, and as no solid food is given to 
produce fsecal accumulation, opium can do no harm, and will keep 
the abdominal contents in a state of rest, a most desirable and nec- 
essary effect. I do not recommend opium in pill, or laudanum, but 
McMunn's elixir, or the deodorized tincture. They can be given in 
enema or by the mouth, and they rarely derange the stomach. I 
prefer phosphate of codeine by hypodermic injection, but it can be 
given in other ways. The combination of morphine and atropine is 
better in some cases. I have never used the ice-bags, preferring the 
poultice mentioned under typhlitis, and as I have never lost a case, 
or had one operated upon, I see no need of changing my practice. 
Without wishing to appear egotistical, I may be allowed to state that 
I have taken several cases after the surgeons had decided for an oper- 
ation, and they have all recovered without it. This does not pre- 
vent me from advising an operation under the following conditions : 
(1) When there is, in an acute attack, tympanites, increase of fever 
with very rapid pulse, and when the pain is rapidly spreading, indi- 
cating general peritonitis. (Osier says, " even if no tumor is pres- 
sent.") (2) In recurrent appendicitis, when a tumor is present, — it 
may partially disappear, but never be wholly absent, and when the 
frequency of the attacks and the continual local tenderness unfit the 
patient for his usual occupations. That such cases do often ulti- 
mately recover is undisputed. On the other hand, perforation may 
occur at any time. The opinion of the best surgeons is that the op- 
eration should not be performed in the interim between the attacks, 
but if the recurrence is attended by the appearance of grave symp- 
toms, operate at once. It is always best for the physician to call in 
consultation, in grave cases, some well-known conservative surgeon. 
I recall. three typical cases which illustrate the policy of conserva- 
tism. One was the case of Mr. K., of Chicago. During the sec- 
ond week of his illness an eminent surgeon was called in consulta- 
tion. He advised an operation if there was no improvement within 
twenty-four hours. The improvement did not appear for several 
days, but the family would not consent to an operation. When 
improvement did occur it was slow and tedious, and during the next 



416 THE PRACTICE OF MEDICINE. 

thirty days there were several recurrent but slight attacks. The 
tumor still remained, but constantly and slowly decreased in size. He 
then removed to New York City, when I placed him under the care 
of Dr. William Todd Helmuth. There he had several attacks, and 
at one time that eminent surgeon decided to operate, but deferred it 
owing to symptoms of improvement. This patient finally recovered 
so entirely that for years he has had no trace of the malady. 

The other two cases were similar. An operation had been pro- 
nounced necessary by two of the best surgeons of Chicago. The 
patients were placed under my care. I treated them under protest, 
giving an opinion that they might recover, but promising nothing pos- 
itive. All these patients were given phytolacca, salol, and turpentine 
internally. An ointment of ichthyol and phytolacca was applied to 
the iliac region ; they were fed on buttermilk, beef broth, mutton 
broth, and milk-gruels. One of the patients was so emaciated that I 
prescribed morrhual, two grains every six hours, with the most excel- 
lent result of increasing food assimilation. 



MEMBRANEOUS COLITIS. 

This is a peculiar croupous inflammation of the colon. It has 
been described by Wood (" Practice of Medicine "), by Woodward 
(Vol. II., "Medical and Surgical Reports of the Civil War"), and 
by Dr. W. A. Edwards and Sir Andrew Clark. Eighty of the 
recorded adult cases have been in women. It is more frequent in 
this country than in England. I have seen several undoubted cases, 
and all but one were cured by homeopathic remedies. Osier says that 
he has twice seen the membrane in situ. " It was closely adherent 
to the mucosa of the colon, but capable of separation without any 
lesion of the surface. The cases are most invariably seen in nervous 
or hysterical women or neurasthenic men. All grades of the affec- 
tion occur, from the passage of slimy mucus like frog spawn to 
tubular casts a foot or more in length. These casts are not fibrin- 
ous but mucoid, and even the firmest consist of dense, opaque, trans- 
formed mucus. It is due to some derangement of the mucous glands 
of the colon, the nature of which is quite unknown." I do not think 
it much different from a peculiar form of catarrhal colitis. 

The disease persists for years, and it is characterized by par- 



DISEASES OF THE DIGESTIVE SYSTEM. 417 

oxysms, at irregular intervals, of severe pain in the bowels, ten- 
derness of the abdomen, teuesmus, and the passage of flakes or long 
strings of mucus, or casts of the bowels. The attacks may last from 
one day to two weeks. Mental emotions or worry seems to bring on 
an attack. Membranes are not passed with every paroxysm. One 
of my severest cases occurred during a painful pregnancy. 

Symptoms similar to those of membraneous colitis have been 
caused by nitrate of silver, muriate of ammonia, colchicum, cuprum, 
nitric acid, veratrum album, asarum, sulphuric acid, and cantharides. 

Treatment. — All the above mentioned drugs said to have caused 
a similiar condition are indicated in special cases. The symptoms 
and their concomitants are recorded in Bell on " Diarrhoea." 

One of my cases was cured by asarum europeum, five drops of 
the tincture four times a day. The paroxysms were characterized by 
tormina, followed by tenesmus, chills, threatening of miscarriage (in 
a woman four months pregnant), and a discharge of long ropes of 
yellow, shaggy, membraneous mucus. 

A German authority reports that after giving euonymin, one- 
fourth of a grain three times a day, discharges of membraneous casts 
and masses followed. In a chronic case under my care, the admin- 
istration of two or three grains of euonymin 2x was followed by the 
expulsion of membraneous casts, with less than the usual pain. There 
has since been no recurrence. I have cured cases by means of col- 
chicum 3x when the paroxysm of pain was followed by membraneous 
flakes. 

Hydrastis and its alkaloids are all indicated in this disease. It has 
been found that when hydrastis is applied to mucous surfaces it first 
causes an increased flow of normal mucus ; at the same time it stim- 
ulates the follicular glands to an increased secretion. If the drug be 
constantly applied, the secretions become yellow, thick, tenacious, and 
ropy. It may become so firm as to simulate a membraneous struc- 
ture. Here we have a drug capable of causing a condition similar 
to membraneous colitis. 

In two cases where other medicines failed to arrest the formation, 

hydrastin was given in one-grain sugar-coated pills four times a day. 

The patient had only two light attacks afterwards. I once gave 

hydrastis lx, ten drops four times a day, with no perceptible results. 

The failure may be explained in this manner : I have observed 

27 



418 THE PRACTICE OF MEDICINE. 

that if hydrastin is to exercise its curative influence over catarrhal 
affections, it must be brought into direct contact with the affected 
surface. The pills were probably not entirely dissolved until they 
reached the colon, while the lx tincture became lost or so mingled 
with the intestinal contents that it failed to come in contact with 
the diseased surface. There is now a method of so coating pills that 
they are insoluble in the acids of the stomach, but soluble in the 
alkaline fluids of the intestines. Such a coating should be applied to 
hydrastis when we desire to affect the colon. 

Muriate of ammonia has an influence on mucous surfaces similar 
to hydrastis, and will doubtless be found a remedy for this disease ; 
being an alkali it will pass through the stomach unchanged and act 
on the large bowel. The symptom — "discharge of glairy tough 
mucus with stool " — clearly indicates it. 

There may be cases requiring iodide of mercury, bichromate of 
potassium, capsicum, nitric acid, and perhaps croton oil. 

To relieve the paroxysms of pain occurring during the expulsion 
of the membraneous secretion adherent to the colon, dioscorea, colo- 
cynth, and hyoscyamus are useful. Very severe pain may need hypo- 
dermic injections of phosphate of codeine, or it may be given by the 
mouth, or in enema, in doses of one-fourth to one-half of a grain. 



CONSTIPATION. 

In a normal condition, every person is supposed to have one 
healthy evacuation from the bowels every day. It matters not at 
what time this evacuation occurs, morning, noon, or night, — but in 
the morning after breakfast is the usual time. Yet many persons 
who seem healthy have a movement of the bowels twice or three 
times a day, generally after meals ; in such cases, if the stool be nor- 
mal and without pain, the condition cannot be considered abnormal. 
Many persons who seem in perfect health have their bowels relieved 
every two, three, or seven days, or even every two or three weeks ; 
cases are not rare in which some degree of good health has been 
maintained for many years, although faecal evacuations have, during 
that time, occurred only at intervals of six weeks or two months. 
In most cases, however, retention beyond the usual period is apt to 



DISEASES OF THE DIGESTIVE SYSTEM. 419 

produce not only local uneasiness, such as tendency to piles and 
flatulence, but also some degree of general disturbance indicated by 
foul breath, loss of appetite, and dyspeptic symptoms. There is one 
form of constipation apt to be mistaken for looseness : the person 
may have several watery evacuations a day, yet an examination of 
the abdomen shows that the colon, and rectum even, is full of irregu- 
lar masses of impacted faeces, that cause an irritation with watery 
stools, while the hard masses are retained in the folds of the large 
intestine. 

Habitual constipation leads to more or less permanent hypertro- 
phy and dilatation of the rectum, rendering this tube less efficient 
for the performance of its expulsive duties. The whole of the large 
intestine may become dilated by its contents, and hypertrophied, the 
mucous surface may be fretted into ulcers, and perforation may ensue ; 
the dilatation may be so great that the colon measures twelve inches 
in circumference ; this dilatation is greatest in the rectum, sigmoid 
flexure, and caecuin. 

When not mechanical, constipation arises temporarily from change 
of diet, scene, or habit, or from anything that interferes with the 
regular performance of defecation. Riding on railway cars is a com- 
mon cause, as is a change from active to sedentary habits. It is a 
symptom of chlorosis and diabetes, and is caused also by a dread of 
defecation, owing to pain at the anus from piles or fissure. 

The purely mechanical causes are : cicatricial stricture, thickening 
of the walls of the rectum, compression from without by tumors, or 
traction of the bowels from their normal position by adhesion, tor- 
tion, strangulation, invagination, and finally from the impaction of 
foreign bodies. But these are conditions for the surgeon, and do not 
come within the scope of this article. One of the chief causes of 
constipation, and one leading to the worst consequences if not attended 
to, is inaction of the liver. I mean partial or complete arrest of the 
normal flow of bile into the intestines. Bile is the natural aperient 
of the human body ; if too much is poured out there is bilious diar- 
rhoea ; if too little, sluggish action. The liver is the crematory of 
the system, where the poisons generated by the processes of elimin- 
ation are burned and destroyed. Of these poisons, the most delete- 
rious are the ptomaines that are formed in the intestines ; if these 
are not burned, or carried out of the body, they are absorbed, and 



420 THE PRACTICE OF MEDICINE. 

cause a host of symptoms indicating poisoning of the brain, nervous 
system, and glandular organs. 

Next to the general blood-poisoning, the injurious effect of consti- 
pation on the heart, is the most important. The poisonous ptomaines 
affect the heart as do digitaline, muscarine, veratrine, and other heart 
poisons. Many of the cases of cardiac disorder which we are called 
upon to treat are due to constipation, and its resultant ptomaine poi- 
soning, aggravated by the mechanical irritation and pressure of an 
overloaded colon. 

The treatment of chronic constipation should be more dietetic and 
hygienic than medicinal ; the following rules, if faithfully carried out, 
will cure nearly all cases not due to mechanical obstruction. (1) 
Take three simple but liberal meals daily ; a small cup of coffee at 
breakfast if its use has been habitual, and at lunch, tea, steeped not 
over five minutes. Avoid pickles, spices, curries, salted or preserved 
provisions, pies, pastry, cheese, jams, dried fruits, nuts, and all coarse, 
hard, indigestible food, taken with a view to move the bowels. This 
eating of coarse, cracked wheat, oatmeal bran, graham bread, and 
other grains prepared with the hulls on, is as reprehensible as is the 
taking of cathartics ; they act by irritating the coats of the bowels 
just as cathartics do, and are as injurious in the end. All cereal 
grains and leguminous seeds can be prepared, divested of their indi- 
gestible envelope, and are much more palatable and nutritious. The 
various u Health-Food Companies " are doing good work in introduc- 
ing such preparations. (2) On first waking in the morning, and 
also on going to bed at night, sip slowly, a quarter or half a pint of 
water, hot or cold ; it is more than probable that one of the causes 
of constipation is the small quantity of water taken into the stomach 
by many persons. (3) On rising, take a cool or tepid sponge bath, 
rubbing the bowels thoroughly, giving a general friction with the 
towel afterwards. (4) Clothe warmly and loosely, see that there is 
no constriction around the waist just over the hips. (5) Walk at 
least half an hour three times daily. (6) Avoid sitting and working 
long in such a position as to compress or constrict the bowels. (7) 
Solicit the action of the bowels every day after breakfast (in some 
cases when there are piles, fissure, or proctalgia after stool, it is better 
to solicit the action of the bowels at night just before going to bed); 
if relief is not gained the first day, wait until the following day, then 



DISEASES OF THE DIGESTIVE SYSTEM. 421 

renew the effort at the same time, but without straining ; percussion 
of the anal orifice with the fingers will aid better than straining. 
Continue these daily efforts until the fourth day, when, if no result 
appears, an enema or laxative should be taken to unload the rectum 
and colon, when the daily effort should be resumed. The enema 
should not be large, not over half a pint, or a pint, unless there be 
impacted faeces high up in the caecal region, when " colon-flushing " 
with warm water and olive oil or glycerine may be necessary; but 
to empty the rectum, a teacupful of soap and water, or glycerine and 
water, or even a tablespoonful of each, will act promptly. Glycerine 
suppositories act just as well and quickly as enemata ; a little boric 
acid placed just inside the sphincter by means of a powder-blower or 
the finger, is often quickly followed by a stool. 

Before having recourse to laxative drugs, try massage ; on rising 
in the morning rub the bowels from right to left along the course of 
the colon with the palm of the hand oiled, or employ a masseur ; I 
have known many most intractable cases cured in a few weeks through 
this method applied by one who understood the proper manipulations. 

There are certain kinds of food that are directly beneficial in con- 
stipation, namely : pearled and granulated oats ; pearled and gran- 
ulated wheat ; bread made of pearled wheat flour, which contains all 
the gluten and starch without the hulls ; gluten flour ; ginger-bread 
(in some cases better without ginger) ; mush or gems made from 
wheatena or " wheat germs "; granola ; baked sweet apples ; bananas, 
figs, prunes, dates, peaches, grape-fruit, oranges ; baked beans and 
peas, sliced tomatoes, veal and lamb, tender steak and mutton chop, 
bacon and butter. Crackers, boiled milk, fine wheat flour, arrow 
root, cheese, pears, and preserved fruits, — all aggravate constipation. 

We will suppose that for a week or two the patient has been under 
the above diet and regime with no satisfactory stool ; the colon is 
found impacted and distended with faecal matter ; large enemata are 
of no avail ; we have given several of the most approved homeopa- 
thic remedies without effect ; what shall we do ? We must not resort 
to active purgation, for it will only make a bad matter worse, but we 
can select a medicine that will, by its mild physiological action, imi- 
tate the natural functions of the bowels, and even increase them. 
One of these is hydrastis. Five to ten drops of the tincture taken 
before meals, by increasing the mucus in the colon (which in consti- 



422 THE PR A CTICE OF, MEDICINE. 

pation is deficient), and by stimulating the muscles of the intestines 
to increased peristaltic action, will generally enable the colon, in a 
few days, to get rid of its contents. 

The next is mix vomica ; one or two drops after meals, acting on 
the muscular fibres of the distended colon, will often in a day or two 
give them strength to expel the accumulated faecal matter. Collin- 
sonia is often more effectual than nux, in doses of five to ten drops. 

Of all laxatives aloin gives the best satisfaction. One-tenth of a 
grain (granule) taken before supper and at 9 P. M. will generally 
give a natural stool the next morning. If the colon is distended by 
an accumulation, a larger quantity of aloin may be required. One- 
half a grain will remove the most obstinate impaction if no organic 
obstruction exists. After the contents of the colon have been evac- 
uated, continue the same regimen recommended above. Aloin acts 
by increasing mucus, stimulating the expulsive muscles to action, and 
by exciting the torpid circulation in the blood-vessels of the intestines. 

At one time in common with most physicians, I feared that aloin 
would cause piles and irritation of the rectum, but I am now satis- 
fied that its careful use for a long period of time will not do so. I 
have given aloin to pregnant women for a constipation that would 
not yield to anything else, for six or eight months, — one-fifth to one- 
fourth of a grain every night or second night, without causing a sin- 
gle symptom of hemorrhoidal trouble. There are various combina- 
tions of aloin with other medicines, which sometimes act better than 
aloin alone ; it is combined with podophyllin, with belladonna and 
strychnine, with nux and hydrastin, and with ipecac. Each has its 
advocates, and each acts well in certain persons. 

Cascara sagrada has been widely advertised and used very exten- 
sively, but I have never been satisfied with its effects ; it seems to 
me to act like crude aloe or podophyllum. 

There are cases that, owing to neglect, and the serious symptoms 
of the head and heart, need very prompt and immediate relief. There 
has not been an evacuation of any amount for a week, the abdomen 
is distended, there is a sense of great weight in the left hypochon- 
drium, the breathing is oppressed, the heart-beat is slow, feeble, or 
irregular, the headache is intense, the head feels full, heavy, and con- 
fused, there is vertigo, the patient is gloomy, cross, and nervous ; 
perhaps no conveniences for giving an enema are at hand ; in such 






DISEASES OF THE DIGESTIVE SYSTE3I. 423 

oases there is no drug that can compare with castor oil for prompt- 
ness and thoroughness of action. One, two, or even four ounces can 
be given without danger ; in emergencies there is no drug so safe ; 
it acts best when given in strong, black coffee. 

In addition to the dietetic and hygienic rules laid down above, we 
can do a great deal with medicines selected according to the law of 
similia ; this requires good diagnostic skill, for we must know not 
only the pathological condition present in the patient, but also the 
pathological capabilities of the medicine. I will give two illustra- 
tions : The patient is an indolent man who eats a great deal and takes 
but little exercise ; he goes out to stool only when he is obliged to ; 
he has frequent inclination, but a trial is ineffectual ; he has a dull 
headache, a coated tongue, is morose and irritable ; his abdomen is 
distended and his food digests slowly ; there is abdominal congestion 
and torpor of the intestinal muscles. Two remedies meet this con- 
dition : opium and nux vomica. Opium causes such a constipation 
primarily, nux, secondarily. If we give opium it should be pre- 
scribed in minute doses, i. e., the 3d dilution, because, if indicated 
primarily, the dose must be small. Opium will often cure such cases 
if you change the patient's habits. Nux is not primarily indicated 
in such a case because its primary action is to cause frequent stools, 
with irregular evacuations, at times knotty, at times thin and small, 
often with ineffectual urging, since the muscles of the colon are irreg- 
ular and spasmodic in action, but not paretic. Now, if you give the 
lx for these primary symptoms you will aggravate the condition, but 
if you give the 3x you will cure. The first case above narrated, 
which simulates the primary action of opium, also simulates the sec- 
ondary effects of nux, namely, intestinal torpor with passive conges- 
tion of the portal system. Here the lx of nux will remove the consti- 
pation in a few days. Each case and each medicine must be studied 
in this manner if we are to be successful. Every medicine known to 
Materia Medica will cause constipation by its primary or secondary 
action. What a vast number we have to choose from, yet how few 
of these are ever used in actual practice ! It is the rare cases that 
require rare remedies. I will mention but a few drugs that I have 
found most useful. 

Bryonia is secondarily homeopathic to constipation ; it is primarily 
a hydrogogue cathartic. If the constipation has been preceded by 



424 THE PRACTICE OF MEDICINE. 

profuse diarrhoea, it will cure in a low attenuation. Its congeries 
are podophyllin, rheum, colocynth, veratrum album, sulphur, bydras- 
tis, and mercurius ; all of these I use in low attenuations. Lyco- 
podium, aluminum, and plumbum, like opium, cause extreme consti- 
pation primarily ; they act best when administered in the 3x or 6x. 
iEsculus, graphites, natrum muriaticum, silica, and sepia, are useful 
in exceptional cases. 

I do not include in the above those cases in which a deficiency of 
bile is the cause of the constipation ; there are many such, and in 
nearly all, this deficiency has something to do with the trouble. In 
any case of constipation, if we discover that the skin is yellow or 
muddy, if the tongue is brown or yellow, if the stools are black or 
too pale, and the urine is loaded with uric acid, some medicine should 
be given that will arouse the bile secreting and excreting action of 
the liver. Pure bile itself will do this, for it is nature's laxative ; 
one or two grains of inspissated ox-gall taken before each meal is 
often the only remedy needed. Euonymin excites the secretion and 
excretion of bile, and causes but slight laxative effect ; a tablet of 
euonymin lx (one-tenth of a grain), before each meal and at nighty 
is very efficient. Iridin lx, mercurius dulcis lx, chionanthus lx, 
chelidonium five drops, or carduus five drops, of the tincture, given 
in the same manner, will cure constipation with deficiency of bile, or 
greatly aid the action of remedies given for other conditions. 



INTESTINAL OBSTRUCTION. 

These obstructions may be caused by (1) faecal accumulation, 
(2) tumors, (3) strictures, (4) intussusception, (5) strangulation, 
(6) twists, (7) knots, (8) concretions, and (9) foreign substances. 
These obstructions are nearly if not all in the province of the sur- 
geon, but some mention may not be amiss in a work on practice. 

(1) Faecal accumulations have been mentioned under the head 
of constipation, but there are instances in which the patient has had 
daily alvine evacuations, while the faecal matter has been slowly 
accumulating in a hernia or protrusion of the colon ; or the patient 
has had insufficient stools for some time ; the stools have been small, 
composed of hard scybalous masses, mixed with mucus. Sometimes 
the faecal masses are channelled by the contents of the upper bowel* 



DISEASES OF THE DIGESTIVE SYSTEM. 425 

and liquid stools may occur. An examination of the colon will show 
hard, irregular masses, which if not removed accumulate by accre- 
tion until the bowel is blocked up. Then the patient has headache, 
vomiting, abdominal distension, with fever and symptoms of ptomaine 
poisoning. (It might be properly called sewer-gas poisoning.) Col- 
itis or peritonitis may result from the obstruction. Occasionally a 
spontaneous expulsion of enormous quantities of hard faecal matter 
may occur, leaving the patient quite well. I know of several per- 
sons of both sexes who allow almost complete obstruction to occur 
from chronic constipation. When the bowels become painfully dis- 
tended they devote two or three days to the task of clearing out the 
bowels by means of an enema and pills of hyoscyamus and aloe. 
They are quite ill during the operation, but when the obstruction is 
removed, return to business until the obstruction occurs in a few 
weeks. Some such cases I have cured by the continuous use of 
strychnia 100th of a grain three times a day, or plumbum 6x given 
in the same manner. Two of the most obstinate cases I ever knew 
were cured by abdominal massage given every day for a month. 

(2) Tumors are to be treated by the surgeon when they are so 
large as to be a permanent obstruction. If small and movable, mas- 
sage will be of benefit, and hydrastis may be useful in some cases. 

(3) Strictures, if organic, require surgical interference, but there 
are instances of spasmodic stricture, which, if they can be diagnosed 
as such, can be removed by nux vomica, belladonna, gelsemium, or 
cocculus. 

(4) Intussusception or invagination can sometimes be treated 
successfully by other than surgical means. The late Dr. Danforth 
reported several cases in which the invagination gave way to the 
injection of an effervescing mixture. A case was once reported 
where a quantity of bicarbonate of soda was thrown into the colon, 
followed by an injection of tartaric acid. The great distension of 
the bowel dislodged the invaginated intestine. Dr. Senn recom- 
mends the insufflation of hydrogen gas, which acts in the same man- 
ner. Purgatives should never be given ; they have caused fatal 
results in many cases. They can only increase the obstruction. 

Kussmaul recommends washing out the stomach. He claims that 
the abdominal distension is relieved, the pressure in the bowels 
above the seat of obstruction lessened, and the violent peristalsis 



426 THE PRACTICE OF MEDICINE. 

diminished. It should be done three or four times a day, and has 
proved a beneficial aid to other measures; in some cases it has 
cured. Flushing the bowel, filling the colon to extreme distension, 
even with warm water alone, has removed the obstruction. It has 
been recommended by Dr. J. Hutchinson that an anaesthetic be 
given the patient ; and thereafter the bowels thoroughly kneaded, 
and a copious enema be given while the patient is in an inverted 
position. Then he is shaken by several strong men, first in one 
position then in the other. 

On consulting Dr. Nicholas Senn's great work on Intestinal Sur- 
gery, the physician will be convinced that when urgent symptoms 
arise, and a skillful surgeon can be found, it is safer to operate than 
to delay or try uncertain procedures. Laparotomy or enterotomy 
has been deprived of nearly all its dangers by the recent improve- 
ments in technique and aseptic precautions. The same advice can be 
applied to (5) strangulation, (6) twists, (7) knots, and to the 
removal of (8) large concretions and (9) foreign bodies. Instead 
of trying to remove them by purging, enterotomy should be re- 
sorted to. 

Like many of my colleagues I have known of many instances 
when a bold and skillful surgeon might have saved many valuable 
lives. Twenty years ago I was called to a talented and promising 
young physician suffering from invagination of the ascending colon. 
He knew when it occurred — on jumping from his high buggy. He 
suffered the most agonizing pain for forty-eight hours, when I 
demanded that a surgeon be called in. He advised enemata, but I 
urged an immediate operation, to which the patient consented, but 
the surgeon would not operate. The patient died in twelve hours. 
The surgeon referred to became famous a few years after by operat- 
ing successfully on a gangrenous intestine. If he had not been timid 
in the above case his fame would have come sooner. 



NON-SURGICAL DISEASES OF THE RECTUM. 

Diseases of the rectum have lately been too much relegated to 
the surgeon. It is supposed by many that nearly all the diseases of 
that portion of the intestine must be treated by some mechanical 
means. The early practitioners of our school went to the other 



DISEASES OF THE DIGESTIVE SYSTEM. 427 

extreme, and believed that all diseases of the rectum could be cured 
by the properly selected remedies. The more conservative practi- 
tioners of the present day deprecate the insistency with which sur- 
geons use the knife, the dilator, and caustics. 

I confess that I belong to the conservatives, and believe that there 
are other measures besides surgical and medicinal which ought to be 
more practiced and advised by physicians. 

Before entering upon the consideration of the non-surgical dis- 
eases, I propose to discuss the preventive treatment of rectal and anal 
disorders, with and without actual lesions. 



HYGIENE OF THE RECTUM. 

The rectum is the lowest portion of the large intestine, extending 
from the sigmoid flexure of the colon to the anus. It is not straight 
as its name would imply, but, commencing opposite the left sacro- 
iliac articulation, it is directed at first obliquely downward, and from 
left to right, to gain the middle line of the sacrum. It then changes 
its direction and curves forward in front of the lower part of the sac- 
rum and the coccyx, and behind the bladder, vesiculae seminalae and 
prostate in the male, and at the back of the cervix uteri in the female. 
Opposite the prostate it makes another turn and inclines downward and 
backward to reach the anus. Seen from the side it offers two curves, 
one corresponding with the hollow front of the sacrum and coccyx, 
and the other at the lower end of the bowels, forming a shorter turn 
in the opposite direction. Unlike the rest of the large intestine the 
rectum is not sacculated, but is smooth and cylindrical, and it has no 
separate longitudinal bands upon it. It is about eight inches in 
length, and at its upper end is rather narrower than the sigmoid flex- 
ure, but becomes dilated into a large ampulla or reservoir immedi- 
ately above the anus. 

The muscular coat is very thick. The mucous membrane is 
"thicker, redder, and more vascular than that of the colon, and it 
moves freely upon the muscular coat. It presents numerous folds 
of different sizes, and running in various directions, nearly all of 
which are effaced by distension of the bowels. Near the anus these 
folds are principally longitudinal, and seem to depend on the contrac- 
tion of the sphincter muscles outside the loosely connected mucous 



428 THE PRACTICE OF MEDICINE. 

membrane. The larger of these are the columns of the rectum. The 
lower ends of these columns or ridges are often connected one to 
another by a web of mucous membranes, making little pockets called 
by anatomists saccull horneri. In the same region are a few papillae 
standing between the pockets. These pockets are much less distinct 
in some persons than in others, but in all perfectly healthy rectums, 
where the mucous membrane is normally thin and elastic, the lower 
end of the grooves between the columns will show hollows which 
sometimes are of considerable depths, but even if shallow, a little 
traction with a blunt hook readily makes them assume the form of 
sacculi or pockets, well adapted to deceive one not aware of the great 
elasticity of the membrane. 

These sacculi have an important physiological function : they 
secrete a tenacious mucus, which is pressed out as the faeces descend 
and lubricates the mass so that it shall pass the anal opening easily. 
If these pockets are slit open or cut away that region becomes dry, 
and the faeces are no longer lubricated ; a kind of rectal constipation 
results, which may cause ulcers, fissures, and external hemorrhoids. 
I am sorry to say that I have seen, not without protest, these nor- 
mal sacculi cut away, under the idea that they were abnormal. I do 
not deny that these sacculi or pockets may become the seat of dis- 
ease. Like the crypts of the tonsils, or those of the cervix uteri, 
they may become inflamed and ulcerated, and may then require 
removal. This fact has been recognized by surgeons for the last 
half a century. The causes of inflammation of these pockets may be 
attacks of dysentery, proctitis, foreign bodies lodging in them, etc. 
I have removed from them small seeds, bits of faecal matter, gritty 
concretions, hulls of wheat and oats, etc., and these foreign sub- 
stances should always be carefully looked for. 

There is another anatomical feature of the rectum which should 
be mentioned. Between the lower ends of the grooves are frequently 
found a few papillae ; white, pointed, like the small teeth of a dog 
or cat, or like the carunculae of the vagina, but smaller. These pap- 
illae are tactile organs, and have their physiological uses. They are 
normally very sensitive, and have nerve connections with the muscles 
which are concerned in the expulsive efforts of the bowels. When 
the faecal mass, or any foreign substance, is brought into contact with 
them, they transmit a reflex influence to the expulsive muscles. It 



DISEASES OF THE DIGESTIVE SYSTEM. 429 

is through these papillae that suppositories, glycerine injections, boric 
acid, and other substances act in causing a movement of the bowels. 
They, like the pockets, may become diseased. They may become 
paretic ana insensible to stimuli, and fail to transmit an influence to 
the muscles governing peristastis or expulsion. This torpidity is one 
of the many causes of constipation. Or they may become unduly 
irritable and cause what is known as the irritable rectum, which is 
similar to the vaginismus due to an irritable state of the caruncles at 
the opening of the vagina. 

Only when diseased and abnormally irritable should they be 
removed. Yet under the influence of the prevailing fashion they are 
often removed when they are perfectly normal. Some of the most 
distressing cases of constipation from rectal torpor I have ever known 
have been caused by the unnecessary removal of normal pockets and 
papillae. 

Now to revert to the subject of rectal hygiene, I contend that 
nearly all the functional or nervous disorders and pathological con- 
ditions of the rectum can be prevented by proper attention. . The 
rectum is analogous to a mouth or buccal cavity, situated at the oppo- 
site end of the digestive tube. One of the first axioms of hygiene is 
to keep the mouth clean, to allow no foreign substance to remain 
between the teeth, or anywhere in the cavity. Why should not the 
same axiom apply to the rectum ? It should, and in a much more 
thorough manner, and yet its cleanliness is almost absolutely neg- 
lected. 

To begin in infancy and childhood ; — the mother, nurse or physi- 
cian should be on the alert to prevent any disorder from becoming 
seated in that sensitive, important part of the bowel. How many 
physicians give it a thought ? In not a single work on Diseases of 
Children have I found a line devoted to this especial subject ! Even 
if the infant be constipated never encourage the habit of giving irri- 
tating laxatives like castor oil, sulphur, or aloe, or of using supposi- 
tories of soap or paper. Instruct the attendant to insert her little 
finger (the nail carefully cut short), oiled with vaseline or olive oil, 
as soon as she observes an effort on the part of the child to evacuate 
the bowels ; slowly and carefully the finger can be introduced with 
out causing any pain or discomfort. If the efforts of the child do 
not expel the finger and the faeces, as it will generally do, then 



430 THE PRACTICE OF MEDICINE. 

slowly stretch the anal sphincter ; if the hard, large mass is only par- 
tially expelled, a finger-tip should be placed in the sulcus just pos- 
terior to the anus, and pushed forward towards the rectum, when 
the faecal mass will readily slip out. The process is singularly sim- 
ilar to the expulsion of the foetal head from the vagina. By this 
simple method the rectum will soon learn to expel its contents with- 
out aid. It will also prevent undue stretching of the muscular coat 
of the rectum, avert piles, contraction of the sphincter, and prolapsus 
recti. The same method applied by a man or woman, young or old, 
will have the same favorable influence over many rectal disorders. 
If, on the other hand, the infant is observed to be frequently strain- 
ing but is not costive, and if with each effort a little wind passes, 
accompanied by a small amount of mucus or faeces, we may be sure 
there is some irritation of the " papillae " or " pockets " ; but in such 
cases there is no necessity for surgical interference. The first thing 
to do is to wash out the rectum with a weak solution of borax, or 
hamamelis, or a one-tenth of one per cent solution of cocaine, using 
of the latter only a tablespoonful. These lotions will usually quiet 
the irritability. I have found that an ointment of one drachm of 
bismuth mixed with two of vaseline had a very soothing effect. If 
there is real proctitis, and the margin of the rectum looks red, 
angry, and protrudes, add to the above a grain of cocaine or half a 
grain of extract of opium. The same method applies to the irri- 
table and inflamed rectums of adults, only the quantity of the ano- 
dyne can be proportionally increased. 

I contend that in any of the rectal troubles of adults, the adop- 
tion of the above methods will enable the patient and physician 
to avoid a surgical operation. The plan I have adopted when con- 
sulted by patients, no matter what their position or station in life, is 
to tell them first to throw aside all false and unnatural modesty and 
to carry out my instructions. I then ask them to give me a minute 
and detailed statement of all the unpleasant sensations which they 
feel in the rectum and region of the anus. I never ask any leading 
questions, but allow them to detail their sensations in their own 
language. If I am in doubt as to the nature of the irritation or 
abnormal sensations, I ask for an examination, but I rarely find this 
necessary. I rarely find it necessary to use a speculum. The fin- 
ger, if at all sensitive in the tactile sense, is sufficient to detect 



DISEASES OF THE DIGESTIVE SYSTEM. 43? 

ulcers, fissures, inflamed papillae or sacculi. Then I instruct the 
patients themselves how to manage the treatment. 

To illustrate the proper treatment I shall narrate a case. At the 
age of seven; the patient had an attack of typhoid fever that left him 
with a complete anal fistula. This was a constant annoyance, and 
indirectly brought on an obstinate constipation, with piles, pruritus, 
and a contracted sphincter. At the age of eighteen these disorders cul- 
minated in an attack of typhlitis which left him in a condition worse 
than before. At the age of twenty he studied medicine and com- 
menced its practice two years later. But the fistula and other rectal 
troubles made life a burden until he reached a point at which he 
determined to- have an operation performed. Coming under my 
care when I was making a thorough study of the anatomy and phys- 
iology of the rectum from such few works as I could find, — for intel- 
ligent and scientific essays on that subject were scarce, — I found on 
examination that the contracted sphincter was the apparent cause of 
most of the discomfort. After several weeks of careful manipula- 
tion, acting on my advice, he succeeded in thoroughly dilating the 
sphincter, using the index finger alone. During this process he 
found the "pockets " filled with concretions, seeds, and hulls, which 
were carefully removed every day, and the rectum thoroughly washed 
out after each morning evacuation. Notwithstanding this thorough 
morning cleaning, the patient was troubled with annoying pruritus- 
ani at night which prevented sleep. He then found on examination 
at night that small particles and scybalse came down during the 
day, and caused the irritation. These were thoroughly removed 
every night before retiring, and the anus and lower rectum anointed 
with bismuth ointment. Then the pruritus disappeared, and greatly 
to my surprise the fistula healed, and has never opened since, now 
nearly thirty years. This experience has led me to the convictions 
stated above, and whenever I have found patients willing to treat 
themselves in the same manner, the result has been gratifying to 
them and to myself, and deprived the surgeon of many interesting 
and lucrative cases. 

The right position during defecation is the natural one, namely : 
squatting with the knees against the chest, and the chin resting on 
the knees. No other position was ever intended. The anatomy of 
the rectum makes this imperative. As before stated the lower por- 



432 THE PRACTICE OF MEDICINE. 

tion of the rectum curves forward just as the vagina does. The 
mechanism of defecation is singularly like that of labor. When the 
head of the faecal mass descends it presses on the posterior portion 
of the rectum, distending the sulcus behind the anus, just as the 
head of the child distends the perineum. Then the mass moves for- 
ward and toward the anterior of the pelvis, and drops downward just 
as the child would if the mother was confined in a squatting posi- 
tion. Now the position which faulty water-closet arrangements 
make civilized people assume is the very one which most increases 
the difficulty of defecation and causes constipation. At first, the 
seat was ten or twelve inches high, but the height has increased of 
late until it is higher than the length from the sole of the foot to the 
knee. This position is not only unnatural but it is most uncomfort- 
able. I believe the position is to blame for many rectal and uterine 
diseases and displacements. The expulsive efforts made in this posi- 
tion are not made in the line of least resistance, and consequently 
some tissue must suffer ; this is generally the contracted sphincter, 
and the attitude explains why fissures are more common at the pos- 
terior border of the anus. 

The proper arrangement in the water-closet should be this : The 
bowl should be small, not over eight inches wide, and sunk in the 
floor. This would allow the natural position to be assumed. If 
there must be a seat it should not be raised above the floor more than 
six inches high and the seat sloping from the front. If defecation 
could always be effected in the natural position in public water- 
closets the danger of contracting infectious diseases would be nil 



HEMORRHOIDS, PILES. 

Hemorrhoids are properly divided into external and internal. 
External piles are either true hypertrophies of the skin, exagger- 
ations of the natural rugose state of the anus, or rounded and elon- 
gated-looking tumors which pass up into the bowel. 

Internal piles are tumors that originate within the anus, but 
which have been forced outside, and may have even put on a pseudo- 
cutaneous appearance from exposure. The two kinds may exist at 
the same time. The causes are : obstructions of the liver and portal 
system ; fsecal accumulation which prevents the return of blood from 



DISEASES OF THE DIGESTIVE SYSTEM. 433 

the terminal veins ; chronic spasm of the external sphincter muscle, 
diarrhoea, dysentery, eating large quantities of meat, drinking alco- 
holic liquors, excessive smoking, a sedentary occupation, the pressure 
of the uterus in retroversion and during pregnancy, eating coarse 
food, or fruit containing seeds, and straining at stool. 

It is astonishing that sensible men and women will sit and strain 
during a difficult stool, when the rectum is packed, and even when 
there is nothing in the rectum. I have known men strain with such 
an effort that a hernia was caused. Many fatal cases of apoplexy 
have resulted from these efforts. Women will strain at stool until 
the uterus is retroverted, or forced through the external outlet. 
They do not seem to know that by the proper use of the oiled finger 
any stool can be made easy, with a little patience. Half the cases 
•of piles are caused by this senseless straining at stool. 

External piles during an acute attack present the following symp- 
toms : The small tabs of hypertrophied skin become swollen, ©edem- 
atous, and shiny, exceedingly painful to the touch, and they some- 
times ulcerate. An oedema may surround the anus, forming a large 
swollen ring of skin and everted mucous membrane all round the ori- 
fice. The color of the hemorrhoidal tumors is red, purple, or almost 
black ; the blood in them can be forced back into the rectum, if there 
is not too much swelling. If irritated they set up a spasm of the 
sphincter and levator-ani, causing great suffering. This spasm often 
prevents sleep and causes great nervousness. There is a constant 
throbbing, and a sensation as if foreign substances were being pushed 
into the anus. This excites a desire to expel it, but any such effort 
aggravates. Walking, sitting, coughing, or sneezing greatly aggra- 
vates the pain. After the bowels have moved the pain is greatly 
increased. There is sometimes a good deal of fever, furred tongue, 
headache, and gastric disturbance. 

Treatment. — If the attack is a first one, and has been brought 
on by excessive eating and drinking, or getting overheated, order 
one-half a glass of Rubinat water, or a dose of Epsom salts, to clear 
out the bowels. If this is objected to, have the patient take an enema 
of one or two quarts of water. I prefer the laxative. Then if there 
is fever give aconite until the temperature is reduced and the pain 
and nervousness relieved. Sometimes five or ten grains of phenace- 
tin is better than aconite. After this the remedies most generally 



434 THE PRACTICE OF MEDICINE. 

indicated are aesculus, aloe, collinsonia, podophyllum, nux vomica* 
and sulphur. In recurrent cases, the treatment should be contin- 
ued after the acute attack is over. The patient should be instructed 
as to diet and method of life, and above all to attend to the toilet of 
the rectum, as directed above. If this is scrupulously carried out the 
attacks will rarely recur. 

My conviction is that too many remedies are recommended and 
prescribed for piles. Out of the sixty remedies mentioned as indi- 
cated by Lilienthal, I have never had occasion to use more than ten. 
Minor attacks of piles will get well unaided in a few days, and we too 
often give credit to the medicine prescribed. In obstinate cases it 
is useless to change the medicine often. If the medicine is really the 
similimum do not change to another every day or two. 

During the intervals treat the patient and not the piles. Get at 
his pathological state, which is generally one of chronic portal con- 
gestion ; remove that and the piles will not return. 

Local applications are often useful to subdue the pain, relax the 
spasm, and reduce the congestion of the veins. For this purpose I 
know of nothing better than a distilled extract of hamamelis, to 
which is added cocaine or resorcin. Warm applications, or cold, if 
the patient prefers, are very grateful. Very hot water will sometimes 
seem to contract the tumors as ice does. An ointment of bismuth 
and cocaine will relieve some patients better than wet applications. 
If the tumors are very large and painful and the contents fluid, they 
can be aspirated or emptied through a small incision. 

If a clot has formed, it can be turned out with great benefit and 
relief to the patient. A little aseptic cotton should be placed in the 
cavity for a few hours ; there will be no hemorrhage unless the cavity 
opens into an internal vein, then styptic cotton is better to arrest it. 
I have cured some cases of external piles by injecting into them a few 
drops of carbolic acid and oil, equal parts, but serious accidents have 
resulted if the acid is thrown into a vein that connects with the gen- 
eral circulation. 

INTERNAL HEMORRHOIDS. 

The causes of internal piles are the same as those of external, but 
in addition, diseases of the genito-urinary system, childbirth, and, 
hereditary influence should be considered. 



DISEASES OF THE DIGESTIVE SYSTEM. 435 

During pregnancy external venous hemorrhoids are frequent, and 
these may and do often pass away after labor in common with vari- 
coses of the legs and labia, but the reverse is the case with regard to 
internal piles. 

The ingenious theory of Verneil as to the anatomical causes of 
internal piles is not accepted by other than French physicians, and 
Allingham presents strong argument against it. Verneil, acting on 
his theory published in 1864, anticipates the practice of Dr. E. H. 
Pratt, and asserts that all internal piles can be cured by " thorough 
dilatation of the external and internal sphincter muscles, no ligatures, 
no clamps, no cautery being needed, and no removal of the piles." 

Fontau (Paris, 1877), in his work entitled " Cure of Haemor- 
rhoids by Forcible Dilatation," asserts the same. 

Varieties. — I am inclined to adopt the three mentioned by Alling- 
ham : (1) capillary hemorrhoids ; (2) arterial hemorrhoids ; (3) 
venous hemorrhoids. Capillary hemorrhoids are small raspberry- 
looking tumors having a granular spongy surface, and bleeding on 
the slightest touch. These piles are situated rather high in the bowel, 
and although small, bleed profusely, and seriously drain the patient's 
strength. They consist of hypertrophied capillary vessels and spongy 
connective tissue. In the course of time, says Allingham, this vari- 
ety passes into the arterial, the change being due to chronic inflam- 
mation of the coats of the capillary vessels, and an increase in the 
size of the arteries. 

Arterial piles are tumors varying in size, sometimes very large, 
having a glistening surface, slippery to the touch, hard and vascu- 
lar, and bleeding freely if scratched ; the blood is bright red and 
spurts out. 

Venous piles are often very large, sometimes the size of a hen's 
egg (Allingham), bluish and livid in color, and rather hard. The 
surface is smooth and shining ; they prolapse very readily, do not 
usually bleed much, but if pricked the blood may be either venous 
or arterial. This kind is commonly found in women who have borne 
many children, or who have an enlarged or retroverted uterus, and 
often occur at the change of life. This species is called " passive," 
and is also seen in men with enlarged and indurated liver, in whom 
the portal system is constantly engorged. This is the form common 
in spirit-drinkers. 



436 THE PRACTICE OF MEDICINE. 

Treatment. — The treatment of each variety should be somewhat 
distinct. I think the physician should find out by an examination 
beforehand, which species his patient has, and prescribe for it, and 
not for the bare symptom. The principal symptoms of capillary piles 
are frequent pains in the back and loins, and in males in the sper- 
matic cords and testicles ; there is great lassitude and partial impo- 
tence. In women the menses may gradually cease, and a condition 
of profound anaemia set in from the constant loss of blood. It is 
evident that these cases should be treated by such internal medi- 
cines as will contract the capillaries, and arrest the oozing of blood. 

Among the best remedies are aurum, mi lief oil, ergotin, hydrastis, 
nux vomica, etc. Locally, suppositories of the same should be used 
at night after the rectum has been thoroughly washed out with hot 
water ; after the morning stool also using the hot water. If the 
sphincter is irritable and contracted, gentle dilatation, even with the 
fingers, is a great aid to the treatment. 

Constipation must not be allowed to exist, and not a particle of 
hard faecal substance should be allowed to remain to irritate the rec- 
tum. If they prove intractable, the rectum should be exposed by 
means of a speculum, and nitric acid should be carefully applied to 
the bleeding surface. Sometimes instead of the nitric, carbolic acid 
can be applied with great benefit. Allingham says he has applied 
an ointment of one-half drachm of the subsulphate of iron to a drachm 
of the unguent of cetaceum ; or in a suppository (two grains to five 
of cocoa butter). " It does not cauterize, or irritate, but acts as a 
sedative, and arrests the hemorrhage with absolute certainty." 

For the arterial piles, the chief remedies are those above men- 
tioned. Also the same topical applications, except the nitric and car- 
bolic acids and the iron. If they do no good in this variety, the sur- 
geon finds here his true sphere of usefulness, and an operation is abso- 
lutely necessary, especially if they protrude at stool and cannot be 
put back or become strangulated. Here Whitehead's or Pratt's oper- 
ation affords the most permanent relief and cure. 

In the venous piles, especially when due to hepatic diseases with 
portal congestion, internal remedies conjoined with local applications 
and absolute cleanliness of the rectum will give excellent results. 

The internal remedies are aurum, aesculus, nitric acid, muriatic 
acid, chelidonium, carduus, nux vomica, sulphur, euonymin, leptan- 



DISEASES OF THE DIGESTIVE SYSTEM. 437 

drin, collinsonia, hamamelis, etc. The best suppositories are those 
composed of hamamelis, collinsonia, and aesculus. If the piles are 
attended with an acid, irritating discharge, a suppository composed 
of hamamelis, boric acid, balsam of Peru, and geranium, two grains 
of each, gives the best satisfaction of any I ever used ; or, if pre- 
ferred, an ointment of the same can be injected after each stool and 
at night. Suppositories of ichthyol, ten per cent, have lately been 
used with good results. 

The diet of patients with venous piles should consist of plain far- 
inacious food with white meats and fish ; fresh acid fruits without 
seeds ; no coffee or spirits, but tea and buttermilk as beverages. 
Plenty of pure water should be drank, and in some cases Carlsbad 
water in the morning, or a teaspoonful of Carlsbad salts in a glass 
of hot water. 

The tendency and desire to strain at stool should be opposed by 
an active exercise of the will, and the introduction of the finger, well 
oiled with the ointment recommended above. If this is done at the 
beginning of a stool and the faecal mass coaxed out, the tumors can 
be kept from protruding, and the desire to strain nearly always pre- 
vented. After stool the patient should lie down or assume the knee- 
elbow posture, and remain in that position half an hour with the 
finger pressed firmly against the anus. 

The treatment of internal piles in women will be very unsatisfac- 
tory until any uterine displacements are first rectified. If there is 
retroflexion or retroversion, the womb should be elevated and straight- 
ened by cervical dilatation and pessaries. After this is done, it will 
often be found that the rectal trouble disappears spontaneously, for 
internal piles are often caused by the pressure of the fundus uteri 
on the rectum, obstructing the free circulation in the hemorrhoidal 
vessels. An Albert Smith soft or hard rubber pessary, bent into a 
suitable shape, is the best instrument. 



PROCIDENTIA RECTI. 

This condition commonly known as " falling of the bowels," must 
be distinguished from the prolapsus of piles. " Prolapsus recti is a 
descent of the lowest portion of the rectum, the mucous membrane 
and submucous tissue, both occasionally thickened, being turned out 






438 THE PRACTICE OF MEDICINE. 

of the anus. Now this condition differs from prolapsed hemor- 
rhoids, thus : The hemmorrhoids exist as separate and distinct 
rounded tumors, while the prolapsus is a fold of mucous membrane 
surrounding the anus without any division into definite tumors, only 
the natural folds of the bowel being observed ; generally there is one 
distinct fold towards the perineum, and the remainder form a horse- 
shoe-shaped projection around the sides and back part of the anus. 
The appearance and touch also of prolapsus differ from piles in its not 
being smooth, hard, and shiny, but soft and velvety." (Allingham.) 

There is a variety of prolapsus which resembles intussusception, 
in which the upper part of the rectum descends through the lower 
part, resembling two cylinders, one within the other. This is often 
associated with polypi of the rectum. 

A procidentia sometimes occurs conjointly with internal hemor- 
rhoids, in which case when the gut is gently returned, there will 
still remain outside of the anus a ring of hemorrhoids. 

Procidentia is more often seen in children than in adults ; it also 
occurs in women who have borne many children, and sometimes in 
old men. It occurs most frequently in children, because in the 
infantile pelvis the sacrum is nearly straight, and also because chil- 
dren are apt to strain violently even when their evacuations are soft. 
Why this is so has not yet been explained, but I would suggest that 
as the reflexes in children are more irritable than in adults, the 
papillae in which the reflex irritability resides may be more sensitive. 
There are also other causes more frequently present in children, such 
as diarrhoea, worms, phimosis, and perhaps stone in the bladder. 

Treatment. — In adults nearly all cases might be cured by the 
patients themselves, by the exercise of common sense. If a patient 
finds that the rectum protrudes, it is almost always because he foolishly 
strains in order to expel a hard stool ; even after the stool is expelled, 
the rectum has been irritated, and there is a sensation as if some- 
thing remained that ought to be expelled, so the patient foolishly 
keeps on straining until the rectum is forced out. The remedy is 
plain. Direct the patient to introduce before the time for stool a 
gluten or glycerine suppository. These will lubricate the lower 
bowel and the anal opening, and soften the hard end of the stool. 
If it does not then slip out easily (or if a suppository is not used), 
direct the patient to oil the finger and introduce it gently into the 



DISEASES OF THE DIGESTIVE SYSTEM. 439 

rectum, and stretch the sphincter, at the same time breaking down 
the hardened end of the faecal mass. When the stool is expelled it 
is easy to explore the rectum and remove all pieces that remain. As 
soon as this is done, the patient should lie down for half an hour 
while he presses up against the anus. I have often advised patients 
to assume the " knee elbow position " after stool, with good results ; 
this allows the bowels to be drawn back and removes the tendency 
to strain. 

The treatment in children is based on the same principle. Moth- 
ers or nurses should never allow children to sit on a vessel or water- 
closet long. It is wrong to place a child in that position and leave it 
there for an indefinite period. This is a common cause of prolapsus. 
If the child does not expel the stool readily, or is inclined to sit after 
it is expelled, it should be taken away and made to lie down. Then 
the attendant should oil the little finger, and introduce it gently 
through the anus, and stretch it towards the anterior aspect of the 
body. This allows the faecal matter to be expelled in its natural 
direction. As soon as it is expelled, firm pressure should be made 
up against the anus for five or ten minutes. This method will- cure 
the worst cases of constipation, and prevent prolapsus. Druit, in 
his " Surgery," recommends that the motions should be passed lying 
on the side, or standing, " one buttock should be drawn to one side 
so as to tighten the anal orifice while the faeces are passing." This 
will answer better for adults than children. 

If the child has dysentery or diarrhoea, it should be made, if possi- 
ble, to evacuate the bowels lying down ; this can be done by patience 
and perseverance. The child will submit after awhile. As soon as 
the evacuation is passed firm pressure should be made on the anus, 
and the recumbent position maintained for a time. It is my firm con- 
viction that one-half of the fatal cases of dysentery in children could 
be saved if this method were persistently followed. If the tenesmus 
cannot be controlled by these means, and in some cases it cannot, it 
is justifiable and necessary to use a small injection of opium and 
starch water. This will quiet the local irritation and keep off for 
hours the desire to strain. If the prolapsus is an old one, and will 
not remain replaced, the case is one for surgery. A few bad cases 
have been reported cured by injecting into the sphincter small quan- 
tities (100th grain) of strychnine. 



440 THE PRACTICE OF MEDICINE. 

Cauterizing the prolapsed mucous membrane in streaks, with 
nitrate of silver, has cured many cases. The medicines recom- 
mended for prolapsus due to constipation, are nux vomica, ignatia* 
mercury, ox-gall, sulphur, aloe, and podophyllum ; not in purgative 
doses, but just enough to arouse peristaltic action, increase the flow 
of bile, and soften the stools. The lx or 2x triturations are effi- 
cient. If it occurs from diarrhoea and dysentery the remedies are 
croton oil, podophyllum, gambogia, mercurius, nitric acid, and aloe, 
all in the 3x to 6x attenuation. 

All violent purgative drugs, especially those which act upon the 
lower bowels, are capable of causing both piles and prolapsus. 
Therefore any such drug may be the remedy for such conditions, i£ 
its symptoms correspond with those of the disease. 



FISSURE AND ULCER OF THE RECTUM. 

Most writers on diseases of the rectum consider fissure and ulcer 
to be similar. 

Allingham says " the symptoms and treatment do not differ what- 
ever form the ulcer assumes, whether it be elongated or club-shaped* 
oval or circular, but as a rule the small circular ulcer is situated 
higher up in the bowel than fissures are, which generally extend to 
the junction of the mucous membrane with the skin, the ulcer being 
more commonly found above or about the lower edge of the internal 
sphincter ani. I think also that in the circular ulcer there is less 
severe pain at the moment of defecation, but it comes on from five 
minutes to a quarter or half an hour after that act, and then is quite 
as intolerable as that resulting from fissure." 

Fissure is not an uncommon affection, but it is not always recog- 
nized. Those who make no careful examination often treat it as 
piles. It has been seen in infants and in very old people. It is 
more frequently found in women than in men. Its usual position is 
dorsal. It may be brought about by the passage of a large, hard 
stool that tears the mucous membrane at the verge of the anus. This 
tear does not heal because at every stool it is re-opened. Another 
cause is the neglect of cleanliness of the parts. A daily wash with 
borated calendula will soon heal a recent fissure if the faeces are pre- 
vented from becoming large and hard, which can be done by means 






DISEASES OF THE DIGESTIVE SYSTEM. 441 

of small injections of glycerine and water, glycerine suppositories* 
or the use of some saline laxative water like Rubinat, taken every 
morning. The ulcers found higher in the rectum are probably caused 
by some lesion of the mucous surfaces by foreign substances in the 
faeces, or as a result of acute proctitis or dysentery. 

The pain from fissures is during defecation, or as soon as the 
faecal mass distends the anal orifice. It is like tearing open a wound, 
or cutting through the skin, and is very excruciating. The patient 
cannot bear to move or stir from one position for some time after 
defecation. The agony induces the sufferer to delay defecation as 
long as possible, with bad results, for the faeces become harder and 
dryer the longer they remain in the bowel, and the pain of expulsion 
is greater. The pain sometimes lasts for hours or all day. 

Does it not seem incredible that rational men and women, ready 
to devise means to relieve themselves of discomfort in other parts of 
the body, should suffer for months and years with this pain and not 
attempt some method of personal relief? It is partly lamentable 
ignorance and partly fear, which prevents the sufferers from trying 
to help themselves. Ninety-nine out of a hundred educated men and 
women have no idea of the anatomy of the rectum. They do not know 
that when a hard, dry, and large faecal mass presents itself at the anal 
opening, there is any other way to expel it than to strain with all 
their power. They therefore forcibly expel the mass, tearing the 
mucous membrane, or forcing down the hemorrhoidal vessels. It 
does not occur to them, in the absence of suppositories, syringes, or 
oil, that they can manage to get rid of this mass, without inflicting 
on themselves injuries that it may take years to cure. 

The free use of saliva, which is equal to oil, will enable any per- 
son to insert a finger into the anal opening and meet the descending 
mass. He can then stretch the sphincter slowly, until it can almost 
allow the faeces to pass out. If not, he can remove the hard portion 
in small pieces until the upper, soft part of the mass is reached, when 
it will pass without injury. Therefore I contend that injury to the 
rectum and anus need never happen, and that fissures, piles, and 
ulcers can be prevented by the use of a little common sense. 

On examination of the anus, with the patient on the side, raise 
the upper buttock with the hand, and then with the finger and thumb 
gently open the anus, at the same time telling the patient to bear 



442 THE PRACTICE OF MEDICINE. 

down. You will then be able to see just within the orifice an elon- 
gated club-shaped ulcer. The floor of it may be very red and 
inflamed, or, if the ulcer is of long-standing, of a grayish color with 
the edges well-defined and hard. I have frequently found these fis- 
sures at the base of a small pile-tumor, or a small club-like papilla, 
or polypoid growth. 

You may, in some cases that present all the subjective symptoms 
of fissure or irritable ulcer, fail after the most careful examination 
to find any lesion. This failure was probably what led Dr. Dolbeau, 
of Paris, to assert that " the essence of this disorder is neuralgia," 
and he defines fissure of the anus as being a " spasmodic neuralgia of 
the anus." 

Allingham, commenting on this assertion, declares that of the 
thousands of patients he has examined, presenting the symptoms of 
fissure or ulcer, he has never failed to discover some lesion, though 
sometimes very slight. 

Dr. Kelsey (" Diseases of Kectum and Anus "), illustrating how 
difficult it is to discover the ulcer, relates a case where, after failing to 
find a fissure or ulcer, he thought he would pass a probe into each of 
the sacculi or pockets ; on entering the third the patient screamed 
with pain, there was spasmodic retraction of the levator and sphinc- 
ter muscles, and the part was forcibly withdrawn from view. On 
opening the sacculi with a probe-pointed tenotome, the ulcer was 
exposed at the base of the pocket, which looked like an ordinary 
fissure of the anus. A cure of the fissure was then easily accom- 
plished. 

Treatment. — For surgical treatment consult Allingham, Pratt, 
Kelsey, or Gross. No medical and topical treatment will avail unless 
the rules for absolute aseptic cleanliness be carried out by the patient. 
In an old number of the " American Homeopathic Review " Dr. Lippe 
gave the indications for several medicines for fissura ani. They 
were ignatia, nitric acid, graphites, paeonia, platina, ratania, rhus tox, 
and silica. I have tried them all and have never seen good results 
from any but ratania, which has the following symptoms : " burning 
in the anus like fire, preceding and accompanying defecation, and 
lasting a long time after it, accompanied by varices." This does not 
show the true symptoms of fissures, but rather of ulceration of the 
sacculi with hemorrhoids. The history of this drug and its use in 



DISEASES OF THE DIGESTIVE SYSTEM. 443 

fissure is interesting. It is a powerful astringent, discovered in 1779 
in Peru by Kuiz, who found that it was used for spongy and bleed- 
ing gums, and all passive hemorrhages. Its botanical name is Kra- 
meria. 

Bretoneau, believing that the rectum was always enlarged by con- 
tinued distension in cases of fissure, and that by restoring it to its 
proper size and power he could cure this disease, prescribed an 
enema of the watery solution of ratany, and actually succeeded in 
curing many cases. Trousseau (Therapeutics) directs it to be used 
as follows : An emollient enema is administered every morning to 
empty the bowel, and half an hour afterwards a solution of a drachm 
or two of ratany in five ounces of water is thrown into the bowel. 
The bowels should be kept open by means of one-fifth to one grain 
of powdered root of belladonna. The patient's sufferings for the 
first two or three days will be aggravated, but this annoyance is 
usually temporary, and is followed by inexpressible relief." 

Hartlaub's provings do not mention constipation as one of its 
symptoms ; but the pains, burnings, and varices are connected with 
loose stools. 

I have cured several cases of fissure or irritable ulcer of the rec- 
tum with piles by following Trousseau's method. I have also used 
a suppository of cocoa butter containing five grains of the extract 
of ratany, with equally good results. Graphites is of no value except 
in the fissures attending eczema. 

Peonia or platina I never use, nor do I believe them of any value ; 
nitric acid is useful in all rectal affections when hepatic disorder is 
the cause. It is of great value when applied as a caustic to ulcers, fis- 
sures, and other open lesions of the rectum and anus. 

Several cerates are of value in such cases. One of the best is 
made by Gross & Delbridge after my original formula given them 
fifteen years ago, and named " sedative saxoline." It is composed 
of calendula, boric acid, and balsam Peru. This should be applied 
(not on the outside) but inside the rectum, and at the anal orifice. 
Patients, unless they are especially ordered, will only rub it outside 
the anal orifice. If they cannot smear it all over the lower rectum 
they should procure some ointment-syringe like Hutchinson's, by 
which they can throw it into the rectum. 

Forcible dilatation is now generally practiced by surgeons for the 



444 THE PRACTICE OF MEDICINE. 

cure of fissure of the anus, but I believe a patient can cure himself 
by gradual, gentle dilatation, and the use of ointments. It may take 
longer, but he will avoid the probability of paralysis of the sphincter. 
Allingham's method is probably the best. He uses a knife through 
the speculum, commencing the incision a little above the upper end 
of the fissure, terminating the cut a little beyond the outer end, so 
that the whole sore is cut through ; the depth of the incision should 
not be less than a quarter of an inch. If there is a bit of inflamed 
skin at the outer end it should be removed with a pair of scissors. 
After this, a few days rest on a sofa is all that is required, with an 
application of the sedative saxoline. When the bowels move for the 
first time they should be aided by an enema of glycerine and water. 
There are cases where neither Allingham's nor Pratt's, nor any other 
local treatment will cure, because the disease is a proctalgia, a true 
neurosis, imitating exactly fissure or ulcer. Such cases require con- 
stitutional treatment, rest, galvanism, a sea voyage, or change of cli- 
mate. I have observed that many persons suffer only when travel- 
ling, or when they become costive ; as long as they have loose evac- 
uations no pain is experienced. Others again have the same pain 
during a diarrhoea. In these last cases I imagine some nerve fila- 
ment is exposed, for the slightest touch will bring on a paroxysm. 
One such case was cured by the application of pure carbolic acid. 
Another by the application, under cocaine, of nitric acid. 



DISEASES OF THE SACCULI HORNERL 

These sacculi have recently been named rectal " pockets," and 
some surgeons consider them always abnormal. Other authorities 
standing just as high consider them " normal structures, whose func- 
tion is to hold mucus which is forced out during defecation to lubri- 
cate the margin of the anus and protect it from hardened faeces." 
(Prof. Smith in Andrews' " Diseases of the Rectum.") The same 
opinion is held by Dr. Andrews himself, a veteran and experienced 
surgeon, also by Drs. Gross, Kelsey, Ashurst, Allingham, Esmarch, 
Curling, and other eminent writers on the Anatomy and Diseases of 
the Rectum. 

The wholesale removal of them cannot therefore be justified or 



DISEASES OF THE DIGESTIVE SYSTEM. 445 

sanctioned as good surgery. As well might the gynecologist remove 
all the crypts and pockets in the uterine cervical canal. But they 
do sometimes become diseased, and when this occurs removal is jus- 
tifiable. 

I have described their appearance in health, and I have often 
observed them in their normal condition. They are lined with a 
beautiful, delicate mucous membrane, which moves freely on the parts 
beneath, and stretches readily in any direction. They are usually 
half-filled with a clear transparent mucus, which can be squeezed 
out by pressing on their lowest portion. When they are in this con- 
dition they should never be meddled with. 

I have frequently seen them in a diseased condition. Then they 
are greatly enlarged, deepened, and of a red, livid color, and filled with 
a purulent and sometimes bloody secretion, and very sensitive when 
the probe is passed into them. Great credit is due to Dr. Pratt (see 
his " Orificial Surgery ") for pointing out the frequency of diseased 
conditions of the sacculi, and the benefit arising from their removal. 
But I believe he goes too far when he asserts that they are not nor- 
mal structures, and that " their removal is always attended with ben- 
efit to the patient, whether they be irritable or not." He adds that 
"after an experience upon thousands of cases, extending over a period 
of several years, I am compelled to advise their thorough eradication 
at all times and under all circumstances." 

It is Dr. Pratt's practice, as well as that of all his disciples, to 
dilate the sphincter, remove all the papillae and hemorrhoidal tumors 
which may be present. I have never been able to ascertain if they 
have ever removed the sacculi alone without dilating the sphincter, 
or any other operation. Therefore their testimony must be taken 
with many grains of allowance. I contend that a proper attention to 
the cleanliness and toilet of the rectum is capable of preventing dis- 
eased conditions of these " pockets." These conditions are nearly 
always caused by the irritation of hard, large faecal masses, or small 
particles of faecal matter, seeds, bran, sand, and innumerable other 
small substances which enter and remain in the sacculi. All these 
causes can be prevented if the directions given under Hygiene are 
fully carried out. The upward firm pressure of the finger, inside of 
the sphincter, all around the rectum, is able to press out of these 
pockets all foreign substances, unless too firmly lodged therein. 



446 THE PRACTICE OF MEDICINE. 

The physician, by means of the speculum, can treat these pockets 
without removing them, in a large majority of cases. If on exam- 
ining them through the speculum they are found in an ulcerated, 
irritable condition, they should be emptied of their contents, and 
with a delicate bent applicator, the end wrapped with a film of cot- 
ton, moistened with peroxide of hydrogen, their cavities should be 
cleansed. If there is pus present, the foaming of the contents when 
brought in contact with the peroxide will be of diagnostic value. 
When cleaned out, apply a fifty per cent solution of the tincture of 
iodine, carbolic acid, or iodized phenol. These measures will cure 
many cases and render their removal unnecessary. Dr. Pratt's 
method of removal is to insert a blunt hook, and raise their roof by 
traction ; then with a curved scissors the expanded pocket is snapped 
off as close as possible to the rectal surface, completely destroying 
the sacculi. I cannot leave this subject without narrating two cases 
which were typical cases of failure, after the operation of removing 
the sacculi. 

(1) A woman of forty was sent to me from a distant city, to be 
treated for cardiac disease, complicated with chronic diarrhoea. In 
a few weeks the heart's action was much improved, but I could not 
benefit the diarrhoea by any remedy. The diarrhoea was " in the 
morning driving her out of bed," but sulphur in the 3d or 200th did 
not benefit her. It was just such a diarrhoea as we invariably find 
in ulcer of the rectum, but on a careful examination of the rectum 
through several different speculums, I could not discover a single 
lesion. The diarrhoea was aggravated or brought on by mental 
emotions or sudden excitement. This led me to believe it to be a 
neurosis of the abdominal and rectal nerves. Through the advice of 
a friend she went to an orificial surgeon who promised a cure. He 
dilated the sphincter (which was too lax already), cut out the pap- 
illae, removed the pockets and a small pile or two, dilated the cervical 
canal and the urethra, and would have dilated any other orifice if he 
had found it. Not the slightest improvement was gained. On the 
contrary she has not been able fully to control her faeces and urine 
since that time, now two years. This case was one of malpractice ; 
there was nothing abnormal to remove, nothing which should have 
been dilated. 

(2) A case of obstinate constipation. All the operations men- 



DISEASES OF THE DIGESTIVE SYSTEM. 447 

tioned in case (1) were performed. There has been no improve- 
ment in any respect, but the bowels are moved with more difficulty 
than before. 

DISEASES OF THE RECTAL PAPILLA. 

As before mentioned these papillae are normal organs, which have 
a distinct function — that of conveying reflex impressions to the 
upper bowels. There are not always the same number in different 
persons, but there are always a few. 

Dr. E. H. Pratt says, " Papillae are not constant in rectums, and 
I believe there is now no dispute as to the necessity of their removal 
when they exist." Dr. Pratt is mistaken, for there are several author- 
ities on anatomy who consider them normal tactile organs. I admit 
that they frequently become diseased, and when that occurs their sen- 
sibility becomes greatly heightened, and may cause abnormal reflex 
irritation ; but we should be sure they are diseased before we remove 
them. Whenever I find them exquisitely hyperaesthetic, I do not hesi- 
tate to remove them, but so long as they present a sharp point,- a conical 
shape, and a white color they are not diseased. When they look red, 
and the artery which supplies them is swollen, or when the point 
becomes bulbous, then the removal of such papillae, and no others, is 
a justifiable operation. When they become diseased they resemble 
neuromata such as we meet with in other portions of the body. I 
have seen some bad results from their removal — a peculiar consti- 
pation such as I have mentioned under Hygiene of the Rectum. 

In one case of chronic diarrhoea the surgeon found a good many, 
and finding nothing else of an abnormal character in the rectum he 
removed them. The result was that the woman who had before that 
time been able to control the stools became the victim of involuntary 
defecation. 

PROCTITIS. 

Inflammation of the rectum may result from extension of colitis 
or from dysentery ; or it may arise from impacted faeces and for- 
eign bodies. It may occur without any complication, as the result 
of exposures to cold, like sitting on damp ground, or a cold stone. 
It may be catarrhal. I have known of many instances in which the 
patient was attacked with sneezing, chilliness, and some fever, and 



448 THE PRACTICE OF MEDICINE. 

soon after complained of a feeling of weight, heaviness, and heat 
in the rectum with a constant desire to defecate. On introducing 
the finger there will be more than usual difficulty in passing the 
sphincter. The bowel will feel hot and there will be throbbing. In 
the first stage the mucous membrane will be moist and smooth. There 
will be involuntary tenesmus, which might be likened to the act of 
sneezing, for during the spasm there is some thin mucus expelled. 
Ijater on the discharge becomes thick and bloody, yellow, white, tena- 
cious, and stringy. It is often mistaken for dysentery or hemor- 
rhoids. I have seen cases when no piles or other lesion existed. In 
children it is often caused by worms. It may be a manifestation of 
gout. Drastic purgatives, and especially aloe, podophyllum, gam- 
boge, rhubarb, mercury, and many other drugs cause proctitis. It 
may be gonorrhoeal, in which case it happens more frequently in 
women than men. Finally, it may arise from irritating suppositories, 
or application of nitric acid and other caustics, and from unnecessary 
and forcible dilatation. 

Treatment. — During the first stage, before any discharge occurs, 
the remedies are aconite and belladonna ; afterwards aloe is the 
principal remedy. No drug gives such a complete picture of acute 
or chronic proctitis (uncomplicated), or when it is attended by piles. 
Gambogia, sesculus, sulphur, and ratany, are all useful in certain 
cases. When the disease is acute, give the 3x ; when chronic, the 
lx. Dr. Allingham says he has cured a great many cases in old 
people with " small doses of aloe," by which he probably means a 
fraction of a grain several times daily. A weak solution may be 
used in an enema, and a small quantity, one-fourth of a grain, in a 
suppository. 

Local Applications. — In the stage of congestion enemata of hot 
water give relief. I prefer for this purpose the instrument used by 
gyneocologists for irrigating the uterus, which allows the water to 
pass out through an extra tube. Borax, distilled hamamelis, borated 
calendula, etc., may be added to the water. If the tenesmus is vio- 
lent and constant, as is often the case with children, a few drops of 
opium in a little starch-water should be injected. In the stage of 
mucous or muco-purulent discharge, injections of aqueous hydrastis 
or a solution of hydrastine (white hydrastis), is almost specific, 
especially when the mucus is thick, tough, stringy, and profuse. 



DISEASES OF THE DIGESTIVE SYSTEM. 449 

Copaiva and cubebs may be indicated by the appearance of the 
discharge, and should be given internally (lx trituration), or better, 
in a pill that would be soluble only in the intestines, and locally in 
the form of injections, or suppositories. I have cured several cases 
with eucalyptus internally, five drops of the tincture every four 
hours, and with injections of eucalyptol water ; muriate of ammonia, 
and asarum may be indicated in rare cases. If the discharge is 
obstinate and resists the above medicines, use a strong solution of 
extract of ratany, extract of geranium, or extract of hamamelis, ten 
grains to an ounce of calendula water, or eucalyptol water. 

The bladder is sometimes severely irritated by sympathy, and 
will require cantharis, triticum repens, corn-silk, buchu, or turpen- 
tine. 

Dr. Strizovere (Sem. Med., 1893, No. 11) recently reports sev- 
eral cases of rectal catarrh : "I have employed an enema consisting 
of a solution of carbolic acid, with success, in three cases of inveter- 
ate chronic catarrh of the rectum. The first patient had for nine 
months been suffering with diarrhoea, the cause of which could not 
be made out, and had been treated in various ways without effect. 
Digital examination of the rectum gave rise to much pain. The 
rectal mucous membrane was velvety and softened. The stools, of 
which there were three or four every day, presented a gelatinous 
appearance. An injection of ten drops of carbolic acid in two tum- 
blerfuls of water was given morning and evening, and retained from 
six to ten minutes. From the third day of the treatment, the motions 
became less frequent, whilst, at the same time, the faeces assumed a 
more natural appearance. At the end of a month the patient was 
cured, without any special attention having been paid to regulating 
his diet during the time he was under treatment. The second patient 
has been ailing for seventeen months, the diarrhoea ceasing at inter- 
vals for two or three months at a time. Complete cure was obtained 
at the end of six weeks under the administration of the carbolized 
enemata. The third patient had an attack of dysentery two years 
previously, from which he recovered, but he had since been suffering 
from chronic catarrh of the rectum. He complained of diarrhoea 
with the passage of mucoid stools, which had proved refractory to 
all previous treatment, but disappeared in a fortnight with the car- 
bolic acid injections." 



450 THE PRACTICE OF MEDICINE. 

PROCTALGIA. — Neuralgia of the Rectum. 

There is no doubt of the existence of a veritable neuralgia of the 
rectum. It may occur without the slightest lesion of that part, and 
the bowels may move normally. It is not connected with defeca- 
tion, but may occur in paroxysms from the same causes as other 
attacks of neuralgia. It is sometimes confined to the sphincter, but 
even then does not act like the pain from fissure or ulcer. Allingham 
believes some cases of proctalgia to be a " very intractable form of 
myalgia." This disease is called by some writers " irritable rec- 
tum." The pain is often so violent as to cause fainting and hysteric 
spasm. It shoots upward into the back and abdomen, and iuto the 
ovaries or testicles. Any violent handling of the rectum aggravates 
intensely. It is analogous to some varieties of vaginismus. Dilat- 
ing the rectum does not cure it, but has aggravated it in many cases 
under my observation. 

Treatment. — Prescribe for the general pathological state and the 
totality of the symptoms. The medicines most useful are arsenic, 
aurum, nux vomica, ignatia, phosphate of potassium, and arseniate of 
strychnine. Ointments or suppositories of hamamelis, belladonna, 
conium, codeine, ratany, cannabis indica, strammonium, or cocaine 
are useful. In one case the only palliative relief was from hypo- 
dermatic injections of codeine, one-fourth of a grain with atropine 
100th grain injected into the sphincter. 

Phenacetin has lately been useful in my hands, three to five grains 
every two hours. Very hot water enemata have sometimes given 
relief. 

PRURITUS ANI. 

Painful itching at the anus is a most distressing symptom. It 
cannot be called a disease of itself, for it is but a symptom of many 
other diseases or morbid conditions. It may arise from disease of 
the liver, internal piles, constipation, anything causing pressure on 
the hemorrhoidal veins so as to retard the return of blood from the 
rectum, errors in diet, gout, parasites, etc. All these causes are 
enumerated by medical writers, but not one mentions that cause more 
potent than all others, uncleanliness of the rectum and anus. If 
the same care were taken of the rectum as is taken of the mouth, 



DISEASES OF THE DIGESTIVE SYSTEM. 451 

diseases such as this would "be rare. The writer was for several years 
a sufferer from this symptom but it disappeared in a few weeks under 
strict local cleanliness. I admit that the use of alcohol, shell fish, 
and all very high seasoned food may have much to do with the causa- 
tion of this pruritus ; it may be a purely neurotic symptom, as any 
other form of pruritus. I am confident, however, that the presence 
of foreign substances and irritating secretions in the lower rectum 
is the chief exciting cause. I also have no doubt that a diseased con- 
dition of the sacculi or "pockets " is a common cause, for I have 
known it to disappear when the pockets were treated or removed. 
The itching and irritation is generally worse at night, especially 
when the patient gets warm in bed, so that the greater part of the 
night is rendered sleepless and wretched. If he falls asleep he 
wakes himself bv a scratching that alwavs aggravates the irritation. 
It may continue all day, and may be caused by coming into a warm 
room from the cold outside air. It sometimes amounts to an actual 
pain — a real proctalgia, in which sharp, needle-like pains shoot up 
the rectum, and down the thighs. 

There is usually not much change in the aspect of the anus. The 
skin may be a little roughened, thickened (and more rugose), just 
around the margin. Sometimes there is a distinct eczematous rash, 
the parts being always moist from the exudation. 

Allingham mentions one condition which he considers character- 
istic in old cases, namely, the loss of the natural pigment of the 
skin. To such an extent does this often obtain that patches around 
the anus extending backward as far as the sacrum and forward to 
the scrotum are of a dull, dead white, the skin looking more like 
white parchment than natural integument, and if you pinch it up 
you will feel that it has lost its normal elasticity. I have seen the 
same condition induced by genital pruritus in women. I have 
.observed the same peculiarity and have known it to be present at the 
anus, perineum, and vulva. 

Treatment. — If on examination no abnormal appearance is dis- 
covered on the outside, you may be sure the disease is in the anus or 
rectum. On stretching the anus, fissures or small piles may be 
found. One of the most common appearances is a small pile with a 
fissure at its base. I have often cured this fissure by one or two 
applications of a pointed stick of nitrate of silver, or nitric acid 



452 THE PRACTICE OF MEDICINE. 

applied on the sharp point of a glass pipette. The small tumor can 
be cured by injecting with a hypodermic syringe, two to four drops 
of equal parts of carbolic acid and olive oil. If no disease of the 
anus is found, inspect the rectum and you will probably find an ulcer, 
or ulcerated sacculi, or some small foreign body in one or more of 
them. Cut down on the margin of the ulcer, or remove the diseased 
pockets or the irritating particles, and treat it as heretofore described, 
and the pruritus will disappear. 

If the anal sphincter is spasmodically or permanently contracted, 
instruct the patient to anoint his finger with bismuth ointment, or 
boric acid salve, and stretch it before and after each stool, at the 
same time removing all detritus from the rectum. If he will not con- 
tinue this method, or if it fails, gently dilate it every few days. If 
the cause is eczema the same rules of cleanliness should be advised, 
and the following ointment prescribed : 

1^ Ichthiol drm. i. 

Balsam Peru drm. i. 

Vaseline . . . oz. i. 

This should be applied to the external parts anjl the orifice. 
Another very soothing ointment, always palliative and often cura- 
tive, is : 

1^ Boric acid drm. i. 

Cocaine gr. v. 

Vaseline oz. i. 

Ointments containing opium should never be used. They leave 
a secondary irritation worse than the original, and tend to increase 
any previous constipation. I have known instances where they led 
to the opium habit. The use of washes does little good. Soap should 
not be used. A teaspoonful of borax to a quart of water makes the 
best lavement. In eczema, soapy water aggravates. Water aggra- 
vates all eczematous diseases. Ointments of zinc, carbolic acid, mer- 
cury, lead, etc., are advised, and may have to be prescribed in obsti- 
nate cases. Internal medicines are of little value. In eczema, graph- 
ites is indicated. Collinsonia has been found useful when piles were 
present. 

Arsenic is said to have cured many obstinate cases in doses of 
one to five drops of Fowler's solution, three times a day, for several 
weeks. 



DISEASES OF THE DIGESTIVE SYSTEM. 453 

Hepar sulphur, internally and topically, is highly recommended 
by Hebra. 

Coffee causes intense pruritus in many persons, and it might be 
tried as a homeopathic remedy. 

Phosphate of soda, when the itching is aggravated in bed at night, 
and is perhaps due to hepatic disorders, or deficient excretion of bile. 

Polyganum (smart-weed) has a great reputation in domestic prac- 
tice. An infusion is used as a wash, and a teaspoonful taken fre- 
quently internally. The following might be used : 

i^ Tinct. polyganum drm. iv. 

Water oz. iv. 

To be applied at night, and one-half an ounce injected. 

A ten per cent solution of nitrate of silver when there is a red, 
raw circle around the anus, will often give prompt relief. 

Suppositories containing cocaine one grain, cannabis indica one- 
half a grain, creosote two drops, menthol one grain, may be used as 
palliatives. 

DIPHTHERIA OF THE RECTUM. 

This condition has been mentioned by several writers. One of 
the most malignant cases of diphtheria I ever saw, in a female child 
of two years, commenced with a deposit of false membrane in the 
rectum and on the vulva. The mother called my attention to it 
before the membrane appeared in the throat. The child had at that 
time high fever ; the next day the tonsils, pharynx, and palate were 
invaded. It should be treated with lotions and an enema of peroxide 
of hydrogen, and the administration of cyanuret of mercury internally. 



PERITONITIS. 

Acute inflammation of the peritoneum. This may be idiopathic, 
but it is said to be rare. When we consider how frequently the 
pleura and pericardium are inflamed, the rarity of idiopathic peri- 
tonitis is very remarkable. When it does occur it is caused by cold 
and exposure, and is generally rheumatic in its character. Osier 
says he never saw such a case, but Bristowe writes as if it were not 
an uncommon affection. I am sure I have seen many cases of rheu- 
matic peritonitis. I recall three, two of which were fatal, that were 



454 THE PRACTICE OF MEDICINE. 

caused by prolonged exposure while bathing; and one fatal case 
caused by remaining too long — four or five hours in the cold water 
— at a natatorium. They began with rigors a few hours after the 
exposure, followed by vomiting, dysuria, fever, burning, aching, tear- 
ing, and twitching pain, beginning in the region of the navel and 
radiating to all parts of the abdomen. The fatal cases were badly 
neglected, and for several days treated with domestic remedies. 
Those which recovered were treated with aconite, belladonna, colo- 
cynth, and dioscorea, and recovered in five or six days. 

One of the saddest cases that ever came under my observation 
was that of a brilliant and promising young man, who after riding, 
asleep, in a railway car, exposed to a draught of cold air blowing 
through the open doors, was after a few hours attacked with a vio- 
lent chill followed by fever, temperature 103°, excruciating pains all 
over the abdomen, with excessive tenderness on pressure, and great 
suffering on the slightest movement. Shortly after the onset I was 
called in and prescribed belladonna and colocynth. In a few hours 
he was relieved. I advised a warm flaxseed poultice to the abdomen 
and ordered the medicines continued all night, and requested to be 
called in the morning if he was not much better. This occurred on 
Monday. I heard nothing more of the case until Friday night at 
midnight, when I was summoned to his bedside ; he was dying, and 
on acquainting the parents with the fact they were profoundly aston- 
ished, and refused to believe me. I requested counsel, who on arriv- 
ing confirmed my opinion. The patient died in a few hours. I 
then learned that his sister saw him on Tuesday morning, and being 
insane on the subject of " Christian Science," insisted on " treating " 
him herself. All kinds of food and raw fruits were permitted, and 
no applications to the abdomen were allowed, but notwithstanding 
the fact that the patient's sufferings increased from hour to hour 
until he died, the sister insisted that he " would get well if he would 
not believe he was sick." No comments are necessary. 

In nearly all cases of peritonitis the principal symptom com- 
plained of is pain. This usually occupies the lower abdomen, and 
is comparatively trivial so long as the patient is perfectly quiet. If 
he has not taken to his bed, he sits, moves, and walks with his 
body bent into a stooping posture. Soon, however, the inflammation 
extends and the pain increases, even during rest, and is aggravated 



DISEASES OF THE DIGESTIVE SYSTEM. 455 

beyond endurance by the slightest movement. He is obliged to lie 
motionless on the back, with the head raised and the legs drawn up. 
He breathes with the intercostal muscles only, and the inspirations 
are very shallow. He shrinks from the pressure of the hand, cannot 
bear the weight of the bed-clothes, or of the poultices and fomenta- 
tions. If he coughs, sneezes, vomits, or hiccoughs, or if he makes 
a deep inspiration, he is in agony. The temperature does not usu- 
ally run very high, 101° to 102°, but in some cases reaches 105°. 

The skin is hot and dry, the face flushed, pulse quick and sharp, 
respirations thirty to forty per minute, the tongue coated and clammy, 
if not dry ; vomiting and thirst may be present, the bowels generally 
constipated, but diarrhoea may be present. The urine is scanty, high- 
colored, frequent and painful, or retained. 

If the disease takes a favorable turn, which it may in a few days, 
the pain, tenderness, and fever subside and convalescence sets in. 
But if the disease tends to a fatal termination, the abdomen becomes 
distended, partly from effusion of fluid, partly from gas in the intes- 
tines, the pain and tenderness may become aggravated, or cease 
entirely (an ominous symptom), vomiting and hiccough appear, the 
temperature falls, the face and extremities become cold and livid, 
cold sweat appears all over, the pulse rises to 141 or 160, the res- 
piration to 40 or 60 per minute, with loss of consciousness, collapse, 
and death. In some cases delirium followed by coma occurs before 
death. 

Puerperal peritonitis arises from extension of inflammation from 
the uterus and ovaries, and is generally associated with pyaemia. 
For a most graphic description of this form of peritonitis, I refer the 
reader to Dr. Comstock's article in the last edition of Leavitt's 
•« Obstetrics." 

Peritonitis from perforation has been considered under the head 
of Typhlitis and Appendicitis. Certain manifestations of la grippe 
may be mistaken for peritonitis. During its prevalence in Chicago, 
especially when it first appeared, several cases occurred in my prac- 
tice that I supposed were rheumatic peritonitis. The pain was 
intense, and was aggravated by the same conditions that aggravate 
the sufferings in true peritonitis. In some patients the temperature 
was high, in others sub-normal. After the attack had lasted a few 
days I expected tympanites and symptoms of gravity, but they did 



456 THE PRACTICE OF MEDICINE. 

not appear. The condition usually lasted several days without 
change, or suddenly changed its location and attacked some other 
portion of the body. 

The so-called hysterical peritonitis may deceive the most astute 
physician, even if he knows his patient to be hysterical. The attack 
may present every feature of true peritonitis, and the collapse itself 
may be simulated. Even the temperature will be elevated. Bris- 
towe mentions a case which recurred three times during a year. In 
my own practice I have had several undoubted cases that were purely 
hysterical. 

The treatment of acute idiopathic peritonitis is not very satisfac- 
tory to either school. It is so often complicated with other condi- 
tions that we cannot treat it as an entity. 

There are but few poisons capable of causing inflammation of the 
peritoneum without causing at the same time enteritis. 

Arsenic, mercury (especially the bichloride), nitric acid, and tur- 
pentine certainly cause peritonitis, but that they cause uncompli- 
cated peritonitis has not been proven. All the drastic cathartics 
may cause an entero-peritonitis ; also cantharis, erigeron, oil of 
pennyroyal, and oil of tansy. Bryonia ought to be able to inflame 
the peritoneum as well as the pleura. The same treatment recom- 
mended for typhlitis will apply to this disease. 



ASCITES. 

Definition. — Dropsy of the abdomen ; an accumulation of serous 
fluid in the cavity of the peritoneum. 

The causes are chronic inflammation of the peritoneum — sim- 
ple, cancerous, or tuberculous ; portal obstruction in the terminal 
branches within the liver, as in cirrosis or other structural diseases ; 
tumors of the abdomen, and enlarged spleen. It may be a part of 
general dropsy, as in chronic heart disease ; or from emphysema or 
cirrosis of the lungs. In some cardiac lesions the dropsy is confined 
to the peritoneum, in which case it is due to secondary changes in 
the liver. It occurs as a result of Bright's disease, and from a 
watery state of the blood. 



DISEASES OF THE DIGESTIVE SYSTEM. 457 

The diagnosis by means of palpation, percussion, and aspiration, 
are fully given in standard works on diagnosis, and need not be 
repeated here. I always empty the bladder by catheterization as the 
first step in diagnosis, for a distended bladder has been mistaken 
for ascites ; so also have an ovarian tumor, pancreatic and hydatid 
cysts. 

The ascitic fluid is not always a clear serum. It may be light 
yellow as in the ascites of anaemia and Bright's disease ; and a 
darker color in cirrosis of the liver. The specific gravity is low, 
1.010, while that in ovarian cysts is 1.020 or 1.015. It is albu- 
minous and coagulates spontaneously, and is sometimes bloody. A 
chylous, milky exudate is sometimes found, and fat globules may be 
seen in it. 

Treatment. — I am sure that in the treatment of chronic peri- 
tonitis I have arrested the effusion by means of arsenic, turpentine,, 
and bryonia. Besides giving these remedies internally I order the 
following mixture rubbed into the abdominal wall twice daily: oil 
of turpentine, half an ounce ; ichthyol, half an ounce ; vaseline, six 
ounces. 

If the distension becomes great, pushing up the diaphragm to the 
extent of causing dyspnoea, and the bowels are torpid, relief may be 
obtained by the use of Epsom salts or elaterium. I have seen a por- 
tion of the fluid apparently disappear after the hydrogogue opera- 
tion of such agents. This is especially the case in dropsy from heart 
diseases. Generally ascites often passes into the stage when tapping 
becomes absolutely necessary. Sometimes repeated tapping results 
in a cure in chronic peritonitis, and gives relief for a long time in 
cirrosis of the liver. I have seen permanent drainage by means of 
Southey's tube make the patient quite comfortable. 

This subject will receive further attention when treating of dropsy 
from heart and renal diseases. 

Apocynum cannabinum has, for many years, had an extraordi- 
nary reputation as a " vegetable trocar." There are very many cases 
on record where it has run off the abdominal dropsy. Sometimes it 
acts on the bowels like elaterium ; at the same time acting as a pow- 
erful diuretic. It does not act as favorably in idiopathic ascites as 
when ascites arises from disease of the heart and liver. 



458 THE PRACTICE OF MEDICINE. 

DISEASES OF THE LIVER. 
I.— FUNCTIONAL DISORDERS. 

Before describing the functional disorders it will be best to give 
a brief view of the functions of the liver in health. 

Murchison in his work on " Functional Hepatic Disorders " gives 
the following resume : 

(1) " The formation of glycogen, which contributes to the main- 
tainance of animal heat and to the nutrition of the blood and tissues ; 
and the development of the white corpuscles. 

(2) The destructive metamorphosis of albuminoid matter, and 
the formation of urea and other nitrogenous products, which are sub- 
sequently eliminated by the kidneys ; these chemical changes also con- 
tributing to the development of animal heat. 

(3) The secretion of bile, the greater part of which is reabsorbed, 
assisting in the assimilating of fat and peptones, and probably in 
those chemical changes which go on in the liver and portal circula- 
tion, while part is excrementitious, and in passing along the bowel 
stimulates peristalsis, and arrests decomposition. 

Prof. Dujardin Beaumetz, in his interesting " Lectures on the 
Modern Treatment of Diseases of the Liver " (recently published by 
G. S. Davis, Detroit), has described the functions of the liver in a 
clear and concise manner ; any attempt to condense his lecture would 
result in marring it, so I shall give it in full. He says : 

" If the anatomy of the liver has made manifest progress the past 
few years, and seems to-day almost complete, it is necessary to bear 
in mind that the knowledge of the physiology of this organ has not 
kept pace with that of the anatomy, and there are still certain func- 
tions of the liver concerning which physiologists are not completely 
agreed. Nothing, perhaps, in the history of medicine is more inter- 
esting than a general survey of the endeavors which have been made 
to find out the functions of the liver. For centuries the world 
accepted with unquestioning faith the doctrine of Galen, who taught 
that the hepatic gland was the centre of animal heat and the organ 
which presided over sanguinification. Then came the discovery of 
the bile, in the seventeenth century, and all the old doctrines were lost 
sight of, and the liver was reduced to the simple office of an emunc- 



DISEASES OF THE DIGESTIVE SYSTEM. 459 

tory, designed to separate from the economy an excrementitious 
liquid, the bile. But modern experimental physiology was destined 
to restore to the organ the high functions which were assigned to it 
by Galen and his school. In fact, it is, as you know, in the liver, 
in the hepatic cell itself, that Claude Bernard places the glycogenic 
function. The same organ also, according to Murchison, Brouardel, 
and Charcot, is the seat of that physiological process which is the 
most manifest expression of the combustions of the economy, namely, 
the production of urea. Lastly, a great number of physiologists are 
of accord in affirming the haematopoietic functions of this gland. 
As you see, the liver has regained in our day its former high import- 
ance. From a therapeutic point of view, the study of the functions 
of the liver is, it must be admitted, much more limited ; we have 
really observed only the action of certain substances on the biliary 
secretion, and are ignorant of the actions of medicaments on the liver 
as a glycogenic organ. As for the liver considered as a reducer of 
urea, physiologists are far from being fully agreed. To the labors 
of Murchison and Brouardel have been opposed other experiments 
and researches, and in particular those of DeSinety and Martin, 
which go to show that perhaps too much has been affirmed as to the 
relation of the liver to urea-formation, and that this excrementitious 
principle has not for its exclusive seat of production the hepatic 
gland, but that it is formed in all the glands and all the tissues of 
the economy. 

" But there is one point in this study which ought to detain us 
longer : I allude to the passage of medicinal substances through the 
liver after having been introduced by the digestive tube, and their 
more or less prolonged sojourn in this gland. This is one of the 
most interesting subjects connected with the physiology of the liver, 
and you will see that by virtue of the experiments of Lussana, Heger, 
Schiff, and Jacques, we may derive therefrom fruitful therapeutic 
results. You are aware that for a long time physiologists have known 
the possibility of the accumulation of certain toxic substances in the 
liver, and it is a rule in legal medicine in cases of poisoning to ana- 
lyze the liver in order to find there traces of arsenic, copper, lead, and 
other substances which have been suspected of determining symptoms 
of poisoning. Paganuzzi, of Padua, was the first to show the differ- 
ence which exists in the mode of elimination when certain salts of 



460 THE PRACTICE OF MEDICINE. 

iron are introduced by the veins of the general circulation, and when 
they are introduced by the mesenteric veins ; in the first case the 
salt is eliminated by the kidneys, in the second by the bile. Lus- 
sana, basing himself on some previous experiments of Schiff, since 
verified by Kosenkranz, researches which have shown that the bile 
secreted in the intestine returns to the liver to be eliminated anew, 
verified the experiment of Paganuzzi, and affirmed as the result 
thereof that the reconstituent and haematopoietic effects of ferrug- 
inous preparations are due to the intimate action on the hepatic 
cells of the salts of iron, which, when introduced by the digestive 
tube into the liver, are then eliminated by the bile, and pass back 
again into the liver by the entero-hepatic circulation described by 
Schiff. 

"In 1873, Hegar, of Brussels, applying to the elucidation of this 
question Ludwig's ingenious method of artificial circulations effected 
in isolated organs, discovered that when blood containing a large dose 
of nicotine is made to pass through the hepatic gland, this alkaloid 
disappears completely in the liver, so that you no longer find any 
trace of it in the hepatic veins. In 1877 Schiff discovered that not 
only does nicotine in passing through the liver lose its toxic proper- 
ties, but that other alkaloids are almost as completely destroyed 
by this gland, and he mentions among the latter hyoscyamin. Lastly, 
in 1880, Victor Jacques, a Belgian physician, completed these 
researches by showing that a certain number of alkaloids introduced 
by the digestive passage sojourn awhile in the liver, and that some 
are in part destroyed in the hepatic gland, and that others may be 
eliminated after a limited time whether by the bile or lymphatics. 

" What is the intimate action of these substances on the hepatic 
cells? Are more or less stable combinations formed with these 
alkaloids, which either destroy the properties of the latter, or which, 
being slowly dissociated by an access of albumen, are thereupon 
eliminated anew ? We do not know, but it is none the less certain 
that these researches enable us to explain facts heretofore very 
obscure. Among these facts is the marked difference which exists 
between the effects of medicaments, and in particular of alkaloids, 
when introduced by the mouth and when administered by the hypo- 
dermic method. The prompt and energetic action of subcutaneous 
injections finds an easy explanation. The medicine passes imme- 



DISEASES OF THE DIGESTIVE SYSTEM. 461 

diately into the general circulation, and brings its therapeutic or 
toxic action to bear upon different parts of the economy. TThen 
introduced by the mouth, however, the alkaloid passes into the liver, 
and there is in part destroyed or tardily eliminated by the hepatic 
gland, hence we see the superior advantage of hypodermic injections, 
which render every day such marked service : and we can never be 
too grateful to TTood. of England, and to my very regretted Master. 
Behier. for having introduced and popularized this method. This 
complete destruction or tardy elimination of alkaloids by the hepatic 
gland gives us a physiological explanation of two other orders of 
facts : (1) the inocuousness of certain poisons introduced by the 
mouth, such as a curare, of which Claude Bernard has shown the 
absolute inefficacy when absorbed by the alimentary canal ; and (2) 
the phenomenon so frequently observed when certain alkaloids are 
given by the mouth, and particularly the alkaloids of the solanaceae. 
I refer to the tardy effect of these alkaloids, and what Gubler has 
described under the name of M accumulation of doses. " You are 
acquainted with all these facts ; you know that when we give atro- 
pine or duboisin in very minute doses and for several days in suc- 
cession, we are in danger of seeing symptoms of poisoning set in. 
although the daily dose remains the same. To-day. by virtue of the 
experiments which I have just mentioned, we have a clear and 
scientific explanation of these facts. The alkaloid is absorbed by 
the digestive tube and fixes itself in the liver. Then, at a varia- 
ble time, it is eliminated into the intestine with the bile, or passes 
into the circulation with the lymphatics, and its presence goes to aug- 
ment the portion which is absorbed into the general circulation of 
the daily dose which you have administered. Permit me to add a 
word : I have just told you that medicaments introduced under the 
skin and passing directly into the general circulation are eliminated 
by the kidneys. I shall show you, as we go on. that if this elimina- 
tion is wanting, the therapeutic effects of the alkaloid cease, and 
give place to toxic symptoms. It would be important to study, as 
opportunity may occur, the influences of the diseases of the liver, and 
in particular of those which completely destroy the hepatic cell, such 
as cirrhosis, on the action of alkaloids introduced by the mouth. 
Here there is an important series of researches to be made, to which 
I invite your attention. But this action of the hepatic gland does 



462 THE PRACTICE OF MEDICINE. 

not pertain exclusively to the vegetable alkaloids, but also, and 
equally, to the toxic alkaloids which we have seen to be incessantly 
produced in the economy. In my work on Diseases of the Stom- 
ach and Intestines, I showed you the important part which these 
ptomaines or leucomaines play in the economy, and I dwelt on the 
elimination by the different emunctories. The liver has an import- 
ant function in the elimination and destruction of these toxic pro- 
ducts. Hence, when its parenchyma is altered, you can understand 
how these toxic substances may accumulate in the blood and pro- 
duce their deleterious effects, effects which play a preponderant role 
in the symptoms which accompany destruction of the hepatic gland. 
This discovery of the morbid poisons which the economy produces 
during life, and the important part which the liver plays in such 
cases, justifies somewhat the view set forth by Lautenbach several 
years ago. 

" The liver is the organ that secretes the bile, and from this point 
of view it possesses for us a great therapeutic interest, for there are 
numerous substances which modify the biliary secretion ; these are 
called cholagogues. But before setting forth the physiological exper- 
iments which demonstrate this action, I shall make a few remarks 
concerning the bile and its secretion in the normal state. Consid- 
ered in the most general manner, bile is constituted of three elements : 
cholesterine, which the researches of Berthelot have caused to be 
classed among the monatomic alcohols, is a fatty substance which pre- 
sents itself to the microscope under the form of rhomboidal tablets. 
You know also that these crystals have a characteristic reaction which 
consists in the red coloration which they assume in contact with sul- 
phuric acid. To-day everyone is agreed in adopting the theory of 
Flint as to the origin of this substance, and Vulpian, in his remark- 
able " Lessons on the Bile," has accepted this view, which regards 
cholesterine as a product of disassimilation of the nervous substance. 
Feltz and Ritter have shown, on the other hand, that this substance 
when it accumulates in the blood does not produce any grave toxic 
symptoms. As for the bile pigment, bilirubin, it is an azotized non- 
albuminous principle derived from the decomposition of the coloring 
matters of the globules, whose properties Tarchanoff and Vossius have 
thoroughly studied ; in fact, from a chemical point of view, there is 
a great similarity between haematin and bilirubin, and you will see 



DISEASES OF THE DIGESTIVE SYSTEM. 46S 

when we come to take up the subject of Jaundice that the possible 
transformation of the former into the latter has given a name to a 
special form of jaundice, hematogenous jaundice (icterus sanguinis). 
We shall see, also, that bilirubin has a characteristic reaction, and 
that the most important and best known is that determined by nitrous- 
nitric acid, which in contact with bilirubin gives a play of colors : 
red, green, blue, yellow, and brown. 

" But the truly essential part of the bile consists in the biliary 
salts, glycocholates, and taurocholates of sodium. You know that 
these two acids easily break up, the one into cholic and cholalic acids, 
the other into taurin and glycocol. Pettenkoffer has given a means 
of readily detecting these acids. If you subject them to contact with 
a mixture of sulphuric acid and sugar, you see them take on a beau- 
tiful violet-purple color. 

" These acids give their principal character to the biliary secre- 
tion, and, in fact, while we have seen that cholesterine originates in 
processes of disassimilation of the cerebro-spinal axis, and the color- 
ing matter of the bile has for its origin the haematin of the blood 
globules, the biliary salts are formed solely in the liver, and are a 
product of a secretion of this gland. This is, you must remember, 
a fact of capital importance, which clearly differentiates the kidney 
from the liver, and while the one does nothing but separate from 
the economy substances which have accumulated in the blood, the 
other produces from elements in the blood special substances which 
are characteristic of its secretion. The experiments of Muller, Leh- 
mann, Kund, and especially the beautiful experiment of Molesschott, 
who performed ablation of the liver in frogs, and did not find the 
biliary acids to accumulate in the blood, are absolutely demonstra- 
tive on this point. Where is the bile elaborated ? Must we admit, 
as Charles Robin suggests, that it is the glands of the bile ducts that 
the secretion of the biliary acids takes place, while to the hepatic cell 
is reserved the glycogenic function ? Must we locate in the hepatic 
cell itself this secretion ? 

" This is a question which the researches of Kolliker seem to 
have solved, for he found the biliary acids in the hepatic cells. It 
is, then, in the cell that the secretion of bile takes place, and remains 
for us to study what are the influences which cause this secretion to 
vary. In the physiological state, the bile, as Colin has shown, flows 



464 THE PRACTICE OF MEDICINE. 

continuously into the intestines, but this flow is subject to intermit- 
tences ; for example, during the periods of digestion, and under the 
influences of certain emotions, the secretion is much augmented. 
We shall study more at length the various modifications in the bil- 
iary secretion in a future lecture devoted to biliary lithiasis. You 
know that when we tie the hepatic artery we do not cause the secre- 
tion of bile to cease. It is the same when the ligature embraces the 
portal vein, leaving the artery intact. What do such experiments 
show ? They prove this, that owing to the numerous anastomoses, 
it suffices that the hepatic gland shall be supplied with blood, it mat- 
ters not from what source, in order to accomplish its function of secre- 
tion. This is so true that when you bleed animals you see the secre- 
tion of bile notably diminish ; on the other hand, if you make an 
intra-venous injection of water, the biliary secretion is augmented. 
But there is a physiological process which notably augments this 
secretion, viz : digestion, or more strictly speaking, the irritation pro- 
duced by food or chyme in the intestinal mucosa. There is in these 
cases a double action : first, an augmentation in the production of bile, 
then augmentation of the excretion caused by increase of the contrac- 
tile movements, of which the gall-bladder and its ducts are the seat. 
" In this regard, there is a fact noticed by Rohrig and Vulpian 
which presents a great interest, viz : that when you inject water into 
the intestine of animals under experimentation, you see the secretion 
of bile augment. As for the influence of the nervous system on this 
secretion, it is not at all doubtful ; at the same time, experiments in 
this direction are not very decisive. Certainly, the vaso-motor nerves 
— vaso-constrictors and vaso-dilators — undergo there, as everywhere 
else, modification from reflex influence, but, as I have said before, 
we need more light on the subject." 



THE ACTION OF MEDICINAL AND OTHER SUBSTANCES 
ON THE LIVER. 

In order to treat understandingly disorders of the liver we must 
ascertain how medicines, foods, or other substances affect the liver. 
We must know what substances increase and what decrease the flow 
of bile. We ought also to know what agents have no effect on that 
function. Formerly it was by examination of the stools that physi- 



DISEASES OF THE DIGESTIVE SYSTEM. 465 

oians thought they were enabled to classify these medicaments, and 
according as the stools were more or less bilious, the medicine was 
considered to have a greater or less action on the liver and was 
called " cholagogue " (bile-producing). This method was not a very^ 
scientific one, and unfortunately in all our provings this method only 
was followed. The provers did not even test the stools for bile (by 
chemical tests), but relied on their odor, color, and appearance. 
Even if tests had been applied, the appearance of bile in the stools 
will not prove that the drug acted directly on the liver, for many 
substances cause an increased flow of bile by their irritation of the 
duodenum and other portions of the intestinal canal. 

A brief history of the latest methods of investigation may be of 
interest. "In 1863 Hanfield Jones was the first to enter on this 
experimental method. He gave certain medicinal substances to 
animals which he afterwards killed, and he then examined the state 
of the liver and intestine ; according as he found the hepatic gland 
more or less congested, he concluded that the medicament had a more 
or less energetic action on the biliary secretion. This, it must be 
admitted, was a somewhat rude and primitive process, which had 
been nevertheless put in usage by previous experimenters and in par- 
ticular by Pecholier in studying the action of calomel. 

" In 1867 and 1868, the British Association, which has done so 
much to elucidate important problems in therapeutics, and in partic- 
ular that of the action of alexipharmic medicines, and of antagonism 
in therapeutics, submitted the question of cholagogues for discussion, 
and appointed a commission consisting of Arthur Gamgee and 
Hughes Bennett to undertake a series of experiments to ascertain 
the action of the so-called cholagogues. This commission made an 
important report, based on numerous experiments performed upon 
dogs, which were all put on the same diet and subjected to the action 
of certain medicaments whose influence on the biliary secretion was 
then studied by careful analysis. In 1873, Rohrig, in Germany, 
completed and perfected this mode of research. He curarized dogs 
and subjected them to artificial respiration. Then, after taking care 
to empty the gall-bladder and tie the cystic duct, he introduced into 
the extremity of the common bile duct a tube ending in a tapering 
point, like a dropping-tube ; then, by the aid of a metronome beat- 
ing seconds, he counted the number of drops of bile flowing in a given 



466 THE PRACTICE OF MEDICINE. 

time by the tube, and thus studied the action of the different sub- 
stances introduced into the stomach or digestive tube of animals 
under experimentation. You see that quite an improvement was 
effected in the way of scientific definiteness, as indicated by the dis- 
tance which separate the method of Jones from that of Rohrig ; but 
progress did not stop here. Rutherford and Vignal, in 1875, 
repeated and improved the processes of Rohrig ; they proceeded at 
first as did the latter experimenters, that is to say, they curarized 
the animal, emptied the gall-bladder, and applied a ligature to the 
cystic duct, but instead of introducing into the common bile duct a 
simple tapering tube, they employed a glass pipette adapted to a rub- 
ber tube, terminated at its distal extremity by another glass tube 
dipping into a graduated test measure ; then they calculated the 
quantity of bile secreted in a given space of time. In some prelim- 
inary researches these experiments proved first of all that curare has 
no action on the biliary secretion, and that during the entire dura- 
tion of the experiments the bile kept its composition almost 
unchanged ; then they showed that in the normal state in the dog the 
quantity of bile secreted is about 20 c. c. per kilogramme of the 
weight of the body and per hour, and it is by relying on this later 
figure that they established the coefficient of cholagogue medicaments. 
This word coefficient, then, indicates the quantity of bile secreted in 
an hour and corresponding to one kilogramme of the weight of the 
animal ; the more that figure exceeds the sum of 20 c. c, the greater 
the action of the medicament on the biliary secretion. Note in this 
connection that the substance under experimentation was not intro- 
duced by the mouth, but inserted into the duodenum." 

I will not give all the medicines that Rutherford and Vignal men- 
tion, only those of special interest to practical therapeutics. The fol- 
lowing are in the order of their importance, according to Rutherford : 

Podophyllin with bile. Sanguinarin. 

Podophyllin without bile. Colocynth. 

Euonymin with bile. Colehicum. 

Euonymin without bile. Phosphate of sodium. 

Salicylate of sodium. Nitro-hydrochloric acid. 

Corrosive sublimate. Baptisin. 

Benzoate of sodium Hydrastin. 

Iridin. Jalap. 

Ipecacuanha. Rhubarb. 

Benzoate of ammonia. Juglandin. 

Phytolaccin. Leptandrin. 



DISEASES OF THE DIGESTIVE SYSTEM. 467 

The experiments of Rohrig, on the one hand, and of Rutherford 
and Vignal on the other, do not agree respecting the relative action 
of these cholagogues on the biliary secretion, as may be seen by the 
following classification : 

According to Rohrig: According to Rutherford: 

1. Colocynth. 1. Podophyllin. 

2. Jalap. 2. Rhubarb. 

3. Aloes. 3. Aloes. 

4. Senna. 4. Colchicum. 

5. Rhubarb. 5. Senna. 

The latest experiments by Provost and Binet differ from those of 
the former. Their method was to establish a permanent fistula from 
the gall-bladder, the track of which was opened from time to time 
for the experiments. The authors lay stress upon this, as they claim 
for the method advantages over the cannula in the estimation both 
of the normal flow and that under medication. This fistula it was 
found did not disturb the health of the animals if fat was kept out 
of their diet. According to these experiments bile itself is the most 
powerful cholagogue known. Next in importance are euonymin, 
benzoate and salicylate of sodium, and salol. Another experimenter, 
Professor Mussy, gives a table of medicaments increasing the flow 
of bile. The following is his order of their activity : aloe, podophyl- 
lin, salicylate of sodium, physostigma, sanguinaria, iridin, bichloride 
of mercury, euonymin, nitro-muriatic acid, ipecac, juglandin, colchi- 
cum, hydrastin, phosphate of sodium, baptisin, leptandrin, and rhu- 
barb. It will be observed that these various experiments do not 
altogether agree. This is probably due to the different methods 
employed. For example, while one .experimenter rates aloe and 
phosphate of sodium very high, others claim that they have but fee- 
ble influence over the secretion and excretion of bile. 

For myself I place more reliance on the experiments of Provost 
and Binet. The medicaments which actually diminish the secretion 
are (according to all experimenters) iodide of potassium, calomel, 
iron, copper, atropine, strychnine, and sulphate of magnesia. It 
was a surprise to all the experimenters that calomel, which from 
time immemorial had been considered the chief of all cholagogues, 
should have, or appear to have, such an opposite action. Dujardin- 
Beaumetz, commenting on this, says : " From the time of Paracelus 
and Von Helmont down to our days, physicians have vaunted the 



468 THE PRACTICE OF MEDICINE. 

action of calomel on the liver ; the green stools produced by this 
medicament were considered an undoubted sign of the elective action 
of calomel on the hepatic gland ; and whatever Stille may have said 
to the contrary, who affirmed that the color of the stools produced 
by calomel were due to a subsulphuret of mercury, it is to-day 
demonstrated by the experiments of Golding Bird and Simon, and 
especially by the researches of Michea, that this coloration is due to 
a biliary pigment. If clinical experience is unanimous in affirming 
the cholagogue action of calomel, quite as decided agreement and 
unanimity exists among experimental physiologists in denying this 
action. Consult the experiments of Scott, Mosler, Kblliker, Muller, 
of Bennet, of Eohrig, and of Rutherford, and all will tell you that 
calomel does not augment the secretion of bile in the dog, but that 
it diminishes it. How are we going to reconcile results so contra- 
dictory ? Some authorities, and in particular Fraser, have attempted 
an explanation ; the experimenters, they say, put themselves in spe- 
cial conditions which were different from what one observes in the 
man whether well or sick. Between the curarized dog, living by 
artificial respiration, and the man, there is a great difference. But 
this argument seems to me to miss the point, and for this reason : 
If it were sound we ought to reject in toto all the experiments on 
cholagogues, for the same objection applies to all the experiments, 
which would thereby be hopelessly vitiated. But this none of the 
authorities are willing to grant, and there is general agreement that 
the results of the experiments as far as most of the medicaments are 
concerned are trustworthy and valid. Murchison seems nearer the 
truth when he says that mercury augments the biliary excretion 
without augmenting the secretion ; i. e., by exciting the contractions 
of the bile ducts, by modifying perhaps the bile itself, calomel causes 
a greater quantity of bile to flow into the intestine, without, however, 
augmenting the secretion of this liquid. I am inclined to take the 
same view of the case as Murchison, and, while giving the prece- 
dence to clinical experience over physiological experimentation, I 
persist in regarding calomel as one of the best cholagogues ; but I 
would associate with it another mercurial preparation, which some 
have supposed to be void of cholagogue properties, namely, corrosive 
sublimate. In fact, while the mild chloride of mercury, when admin- 
istered experimentally, diminishes rather than augments the biliary 



DISEASES OF THE DIGESTIVE SYSTEM. 469 

secretion, the corrosive chloride, on the contrary, according to Ruth- 
erford, augments this secretion ; therefore, I advise you when you 
wish to obtain the full benefit of the salts of mercury in the treat- 
ment of hepatic affections, to combine calomel with corrosive subli- 
mate, and to prescribe pills containing ten centigrams of calomel 
and two milligrams of the sublimate. These pills, in the dose of 
one or two at bedtime, have a marked cholagogue effect." 

One of the most interesting and ingenious articles on the action 
of calomel and other mercurials is by Professor W. H. Porter (in 
" Merck's Bulletin," July 15, 1892). He says : " The action of the 
mercurials upon the hepatic function is exercised in three successive, 
characteristically distinctive stages, to-wit: as stimulants, as chola- 
gogues, and as depressants. As the mild chloride, or calomel, pos- 
esses all these qualities to a marked degree, it is perhaps the best exam- 
ple by which to elucidate the complete action of mercury upon the 
hepatic and digestive functions. The blue mass and the gray pow- 
der act in the same manner ; but, if anything, are a little less active. 
The bi-chloride has a similar action ; but its more irritating proper- 
ties make it less valuable, or even useless, as a cathartic principle. 
Still it can be used as a powerful hepatic stimulant, and as an 
adjunct to the cholagogue function of calomel. The exact modus 
operandi by which mercury in any form produces the wonderful 
results upon the system that have been attributed to it for ages has 
always been more or less in doubt for the lack of a logical explana- 
tion ; yet the most skeptical, after watching the effects of a few doses 
of this drug upon the human system, cannot deny the power and 
utility of mercury. Taking the stand that the inorganic compounds 
are not decomposed within the animal organism, no time need be 
wasted in speculation regarding the decomposition of any of the mer- 
curials into other compounds. How then shall the action of mer- 
cury and its compounds be explained ? Calomel, for instance, is 
almost insoluble ; consequently it in itself is comparatively non-irri- 
tating to the intestinal tract. At the same time it is known to be 
one of the most active cathartic compounds of mercury. Two almost 
contradictory propositions. The cholagogue action of calomel cannot 
be explained by any direct irritating action which it can produce 
upon the alimentary tract, through the increased peristalsis, by reflex 
irritation, causing an increased flow of bile. This non-irritating 



470 THE PRACTICE OF MEDICINE. 

character of calomel is just what gives it its chief power. Passing 
down the alimentary tract without producing irritation, it is steadily 
absorbed into the entero-hepatic circulation and carried up to the 
liver. At this point of the animal economy, the mercurial appears 
to act like a foreign body, and the hepatic cells, by their selective 
action, pick up the little particles of calomel from the blood, and 
eject them into the capillary bile-ducts. In accomplishing this task 
the hepatic cells are called upon to perform more work ; and if the 
amount of the calomel passed through the liver is small, its action is 
simply to stimulate the organ to a little greater activity. For a time 
the hepatic cells secrete a little larger quantity of bile, and such as 
has a little better quality. Up to this point the calomel has only 
been stimulating and physiological in its action. If now the calo- 
mel is administered in larger quantities, either by frequently repeated 
small doses or in one large dose, the eliminating action of the hepatic 
gland is greatly augmented. At the same time the protoplasmic ele- 
ments which constitute the hepatic cells are stimulated by the pass- 
age of this foreign body through their substance, to a more active 
production and elimination of the bile acids. When sufficient calo- 
mel has reached the liver to produce this copious flow of the bile 
acids, the acids are discharged into the capillary bile-ducts more 
rapidly than they react upon the alkaline phosphates or carbonates 
and form the normal and neutral bile-salts. When this hyper-secre- 
tion of the bile acids is established, a cholagogue action is developed. 
This action, however, can be only temporary in character, because the 
protoplasmic vitality will in a comparatively short time be exhausted. 
After this excessive production of the bile-acids and their discharge, 
together with the calomel, there is a period of protoplasmic exhaus- 
tion, in which the bile-producing function of the liver is held in abey- 
ance. Viewed in this light, calomel and its class of mercurials may 
be stimulating, cholagogue, and depressing in their action upon the 
functions of the hepatic gland, — one condition following in quick 
succession after the other. The rapid intestinal peristalsis and fre- 
quent discharges from the bowel are not the direct result of the mer- 
curial action, but a secondary effect, which has been brought on by 
the irritating properties of the bile acids so copiously discharged into 
the intestinal canal, as just shown. This fact is established by the 
lack of cathartic action by calomel in cases of the occlusion of the 



DISEASES OF THE DIGESTIVE SYSTEM. 471 

common bile-duct ; and, furthermore, by the counter-test that where 
bile acids are administered medicinally, a brisk cathartic and chola- 
gogue action is at once established. This hyper-secretion of the bile 
acids and its consequent effect upon the intestinal tract is not in any 
sense a physiological action, but it is strictly a pathological process. 
But by developing this abnormal condition in the functional activity 
of the hepatic gland, the liver-cells are stimulated to perform an 
abnormal amount of work, often vicarious in its nature, and by which 
the cells are empowered to expel many abnormal and by-products 
from the system, a task which in their normal condition they are 
absolutely unable to perform. In this manner nature rids herself of 
many foreign and offending substances, which, if allowed to remain 
and multiply within the system, would in a short time destroy the 
animal vitality, a result too often seen in cases imperfectly treated. 
The period of inaction, which is imposed upon the hepatic cells as a 
sequel to this excessive action, gives the protoplasmic elements a 
chance to rest and to imbibe a more serviceable nutritive pabulum, 
thus augmenting their nutritive activity and enhancing their func- 
tional vitality. When the hepatic cells again resume their physio- 
logical work, they are in a condition of high nutritive tone ; and con- 
sequently the secretory and excretory work of the liver is more per- 
fectly effected. The intestinal and hepatic transmutation of the 
food-elements is more perfectly accomplished ; and as a natural 
sequence all the nutritive processes of the body are intensified ; secre- 
tion and excretion in general are more perfectly performed ; and the 
animal vitality is raised to a higher standard. If the system has 
been poisoned by any form of microbic or ptomainic toxin, or is the 
seat of any inflammatory action, toxic or otherwise, the organism is, 
by the above described processes, placed in the best possible condi- 
tion to destroy the aetiological factors and remove the resulting patho- 
logical processes, and thus restore everything to a normal condition. 
By a somewhat similar physiological action the well-known anti- 
phlogistic power of the mercurials can be explained. Following this 
method of action for the mercurials, ptyalism and all that class of 
toxic symptoms produced by mercury and its compounds can be 
rationally explained. The same reasoning also shows clearly that the 
size of the single doses has little if anything to do in determining the 
liability to mercurial salivation. If from any cause the hepatic cells 



472 THE PRACTICE OF MEDICINE. 

are inactive, and thus fail to respond to the presence of the mercu- 
rial salt and to eliminate it as speedily as it reaches the hepatic gland, 
then the mercurial will pass over into the general circulation ; where 
finally the salivary glands will attempt to perform the work of elim- 
ination that should have been accomplished by the liver cells. In 
like manner, when the calomel is given too freely, or when opium is 
given to check the cathartic action, the hepatic cells either become 
exhausted from over-taxation, or they are retarded in their action by 
the opium ; and then the mercurial passes into the general circula- 
tion. Thus, again, the toxic symptoms with salivation will be pro- 
duced. So long, however, as the hepatic cells retain their selective 
and excretory activity it is absolutely impossible to develop the toxic 
symptoms of mercury. The use of enormous doses may become the 
cause of exhausting the hepatic cells, whereupon poisoning will, of 
course, rapidly ensue." 

There are some points about the experiments with drugs on the 
liver which should be carefully considered. 

(1) It has been suggested that although these drugs caused an 
increase or decrease of bile in the canine liver, they need not there- 
fore have the same effect on the human liver. But this objection is 
not valid, because experiments prove that all these drugs produce the 
same intestinal, gastric, and general effect in the dog as in man. 
The dog is really nearest to man in its gastric, intestinal, and hepatic 
functions. 

(2) In no experiments were repeated small doses used which 
approximate our lowest attenuations. This is the weak point in all 
these experiments. The doses used were very large, often toxic, as 
seven to fifteen grains of podophyllin ; three to five grains of iri- 
din, euonymin, hydrastin ; and ten grains of jalap or colocynth. But 
the use of such large quantities led to an important discovery, 
namely : that if the doses were large enough to produce violent 
purgative action the secretion of bile was diminished. Another dis- 
covery was that if a very large dose was given and did not purge, 
the secretion of bile was arrested or diminished. This shows the 
futility of large doses of cholagogues given to increase the flow of 
bile. It shows, too, that an overwhelming dose of a cholagogue drug 
has the same effect as the secondary effect of the same drug, for in 
many of the experiments after the first increase of bile, there 






DISEASES OF THE DIGESTIVE SYSTEM. 473 

appeared a notable decrease. This is shown in practice, for the old 
school well knows that mercurials act in that way. Not only this, but 
it is well known that cholagogues, like anodynes, require an increase 
of the dose to continue specific effect. 

(3) It was observed that the cholagogue effect of all the drugs 
was greatly increased when given mixed with bile. In fact some of 
the drugs would not cause an increase of the secretion of bile, unless 
a small amount of bile was allowed to pass from the gall-bladder 
into the intestine, or unless some ox-gall was mixed with the drug. 
These facts prove to my satisfaction that when we prescribe bile- 
producing medicines in bilious diarrhoea, we should give the very 
smallest doses, much smaller than when the stools are deficient in 
bile. 

(4) It was observed that in some cases where the quantity of 
bile was increased, its solid constituents were not decreased during 
the hours when the drug was acting. The bile was thinner, but the 
constituents were the same qualitatively. In other cases the amount 
of bile, both quantitatively and qualitatively, was increased. 

(5) The question arises, How do these drugs act? Do they 
increase the secretion of bile by irritating the duodenum or small 
intestines ? This cannot be, for the drugs which most cause such 
irritation really decrease the secretion of bile, and some drugs which 
do not act on the intestines at all increase greatly the secretion 
of bile. 

Do drugs stimulate the hepatic cells by increasing the stream of 
blood through the liver ? This may be a cause in some cases, but 
not as a rule, for it has been observed that drugs that dilate the 
intestinal capillaries do not necessarily increase the bile. 

Rutherford, Headland, and Porter all believe that " the effect of 
hepatic stimulants is to be assigned to a direct action of their mole- 
cules upon the hepatic cells or their nerves." One of the chief 
functions of the liver is to seize upon the molecules of metals, alka- 
loids, glucosides, and perhaps resinoids and oils, and destroy their 
toxic qualities to a certain extent. The molecules which the hepatic 
cells cannot destroy they store up or eliminate. 

The digestive tract is a wonderful and mysterious laboratory. It 
separates ultimate active principles from all organic substances not 
used as food. These active principles, purely molecular, finer than 



474 THE PRACTICE OF MEDICINE. 

any chemist can conceive, are sent to the liver to be destroyed, or 
appropriated by the hepatic cells. Thither also are carried the 
molecules of all inorganic substances having an affinity for the liver. 
The molecules of mercury, copper, iron, lead, and other minerals 
have been found in the liver. It also attracts to destroy, or store up 
for some unknown use, the toxic alkaloids formed in the intestines — 
those ptomaines and leucomaines which are such virulent poisons. 
I have heretofore stated my belief that the curative powers of all 
drugs reside in their molecules. There is no dynamic, imponderable, 
or immaterial influence residing in drugs. These molecules act 
either by contact with the cell itself or on the nerves which supply 
it. When a drug is so attenuated that the molecules are absent or 
nearly so, then the curative power is lost. This may occur in some 
drugs in the sixth, in others in the twelfth or even higher. 

There are some causes to be considered which may hinder or alto- 
gether prevent the action of the best selected cholagogue remedy : 
€. g., we may give the lx or 3x of podophyllin when the secretion of 
bile is scanty or absent, and are surprised that no expected effect 
occurs. This may not arise from a wrong selection of the drug, but 
because the intestinal contents are abnormal — that certain ptomaines 
are formed therein ; are absorbed and carried to the liver, and that 
the hepatic cells are so busy in destroying or eliminating them that 
the molecules of podophyllin cannot find entrance to them. 

Another cause may be the depression of function caused by a fee- 
ble circulation of blood through the liver. This condition does occur 
in some disease of the heart, and some disorders of the intestines, as 
in dysentery or cholera. 

LITHiEMIA. 

This term was introduced by Murchison to designate certain symp- 
toms, due, as he supposed, to functional disorders of the liver. His 
views have been widely adopted, but of late there has been some dis- 
sent from them. 

Murchison defines lithsemia as follows : " When oxidization is im- 
perfectly performed in the liver there is a production of insoluble 
lithic (uric) acid and lithates (urates) instead of urea, which is the 
soluble product resulting from the last stage of oxydation of nitrogen- 
ous matter." 



DISEASES OF THE DIGESTIVE SYSTEM. 475 

So long as the lithic acid and lithates are eliminated in a soluble 
form through the kidneys, no harm is done to the general system. 
But when this does not occur nearly all the important organs suffer, 
and the poisonous effects cause those conditions known as bilious- 
ness, gout, indigestion, etc. The causes of this condition may be 
summed up in a few words — imperfect digestion, with the formation 
of toxines which the liver has not functional activity enough to destroy ; 
a sedentary life, without exercise enough to keep up the normal func- 
tional vitality of the organs of digestion and elimination ; eating too 
much, and the abuse of alcoholic liquors. Murchison enumerates 
the following as the most common symptoms of this condition : " (a) 
A feeling of weight and fulness at the epigastrium and in the region 
of the liver, (b) Flatulent distention of the stomach and bowels, 
(c) Heartburn and acid eructations, (d) A feeling of oppression 
and often of weariness and aching pains in the limbs, or of unsur- 
mountable sleepiness after meals, (e) A furred tongue, which is 
often large and indented at the edges, and a clammy, bitter, or metal- 
lic taste in the mouth, especially in the morning, (f) Appetite often 
good ; at other times anorexia and nausea, (g) An excessive secre- 
tion of viscid mucus in the fauces and at the back of the nose, (h) 
Constipation, the motion being scybalous, sometimes too dark, at 
other times too light, or even clay-colored. Occasionally attacks of 
diarrhoea alternating with constipation, especially if the patient be 
intemperate in the use of alcohol, (i) In some patients, attacks of 
palpitation of the heart, or irregularity or intermission of the pulse 
(usually only when sitting or lying), (j) In many patients, occa- 
sional attacks of frontal headache, (k) In many patients, restless- 
ness at night and bad dreams. (1) In some patients, attacks of 
vertigo or dimness of sight, often induced by particular articles of 
diet." 

To which I will add melancholia, amounting sometimes to insan- 
ity, and violent neuralgias of the face, head, and other parts of the 
body. Among the conditions which he says may be caused by lith- 
semia are urinary calculi, oxaluria, biliary calculi, degenerations of 
the kidneys (he believes bilious lithaemia to be one of the chief causes 
of Bright's disease); structural diseases of the liver ; degeneration of 
tissues throughout the body ; arterial sclerosis, etc. 

Osier, who is always skeptical, says : " It is by no means sure 



476 THE PRACTICE OF MEDICINE. 

that, as Murchison supposed, the essential defect is a functional dis- 
order of the liver, disturbing the metabolism of the albuminous ingre- 
dients, nor is it at all certain that the only offending substance is 
uric acid. " Deficient oxidation is probably the most essential fac- 
tor in the process, with the result of the formation of less readily 
soluble and less readily eliminated products of retrograde metamor- 
phosis." 

One of the most prominent signs of lithaemia is the presence in 
the urine of an excess of uric acid. 

The amount of deposit does not always indicate the amount pres- 
ent in the urine. Clear urine which does not deposit a sediment or 
thicken on cooling often contains a large amount of uric acid (Bence 
Jones). The uric acid usually occurs in combination with ammo- 
nium and sodium, forming acid urates, or it may separate from its 
bases and crystallize in cubes and prisms of a deep red color, look- 
ing like grains of cayenne pepper. The late Dr. J. W. Dowling, of 
New York, was a good pathologist and a successful physician ; his 
views of lithaemia, embodied in one of his lectures, are so excellent 
that I quote those portions of it that are most practical. 

" Although arising from the same cause, a distinction should be 
made between gout and lithaemia, and Murchison, in his celebrated 
Croonian lectures, delivered in 1874, made this distinction — defin- 
ing gout as a condition in which the urate of soda crystallized out 
into the cartilages of the joints and into other portions of the body, 
giving rise to a train of symptoms familiar to us all, and known and 
described by all of the ancient medical writers as gout. Although 
every gouty subject at some period of his illness suffers from lith- 
aemia, every lithaemic subject does not by any means suffer from gout. 

" In considering the functional disturbances and organic diseases 
arising from the accumulation of lithic acid in the blood, the ques- 
tions naturally arise : What is lithic acid ? and why this accumula- 
tion in the blood ? 

" In the healthy subject, that great glandular furnace and chem- 
ical laboratory, the liver, is capable of transforming any excess of 
nitrogenized matter which may result from metabolism of tissue or 
exist in the food consumed, into the highly soluble excrementitious 
substance known as urea. This excrement is eliminated from the 
blood with which it has become combined, mainly by the kidneys, 






DISEASES OF THE DIGESTIVE SYSTEM. 4,71 

and to a much less extent, by the skin. In certain derangements 
of the liver, kidneys, and nervous system, but principally of the liver, 
the nitrogenous waste is not converted into urea but into uric acid, 
a comparatively insoluble excrementitious and toxic substance. In 
a perfectly healthy state of the kidneys, this poisonous substance is 
eliminated with the urine, but in its passage through the urinary 
tubules, irritation is set up, and if the quantity be large and the irri- 
tation long-continued, the function of the renal epithelium is impaired 
and is not properly eliminated from the system, and consequently 
accumulates in the blood. 

" There are foods which are readily digested, never taxing the 
most sensitive stomachs and livers, and leaving behind but little waste, 
which must be gotten rid of in the form of excrementitious matter. 
Then there are foods, some of them rich in nitrogen, which try the 
strongest digestive organs and leave behind excrementitious waste 
which, in its elimination, will severely tax the various organs con- 
cerned in its excretion ; food, perhaps, which draws so heavily upon 
the working powers of the assimilative organs as to seriously impair 
their functions, in time entirely destroying them. The more rational 
kinds of food which supply all the requirements of the system may 
be compared to the coal of better quality, the urea and other readily 
excreted refuse matter remaining, to the fine ashes, which, with ordin- 
ary care, never accumulate and never disturb the working of the fur- 
nace, until, from the natural effects of age, it is no longer competent 
to do even ordinary work. But it is a fact, familiar to us all, that 
too large a quantity, even of good coal at any one time, will clog the 
furnace and interfere with proper combustion ; so will too great a 
quantity of good and rational food, at any one time, disturb the func- 
tions of the liver, stomach and intestinal canal. 

" The poorer quality of coal may be likened to food too rich in 
nitrogen and to irrational articles of diet which disturb the stomach 
and derange the liver ; the refuse matter of the coal, in the form of 
clinkers, to uric acid which accumulates in the system, by its presence 
disturbing the functions of all the organs of the body, developing 
organic diseases in many of them, and permanently injuring, perhaps 
ruining, the kidneys in their efforts to eliminate it from the system. 
We have all experimented with such coal in our houses. We have 
all, time and again, taken such food into our stomachs. It is no 



478 THE PRACTICE OE MEDICINE. 

exaggeration to say that nearly, if not all, of the cases of that form of 
Bright's disease known as chronic interstitial nephritis are caused 
by the presence in excess, in the blood, of this excrementitious sub- 
stance known as uric or lithic acid, and that by far the greater num- 
ber of cases of chronic catarrh of the bladder, in middle and advanced 
life, and nearly all of the cases of renal and urinary calculi, result 
from the same cause. 

" There is no denying the fact that a large portion of the ills to 
which man, and woman too, are heir, results from the presence in the 
blood of an excess of waste material in the form of lithic acid, and that 
this excess results, in by far the greater number of cases, from actual 
indiscretion, violation of nature's laws. Many of the so-called cases 
of neurasthenia — the new name for the fashionable and flattering 
disease, nervous prostration or exhaustion — are cases of lithaemia 
which can be cured, — this I know to be a fact, — by proper diet, the 
avoidance of stimulants and drugs, and a proper amount of physical 
exercise, and, with some, more brain work, for I believe that brain 
work is as necessary to some men as is physical exercise to others. It 
is painful to see in our large towns and cities the number of men and 
women whose main object in life seems to be to kill time. Instead 
of their chronic ailments arising from nervous exhaustion or prostra- 
tion, it is more than probable that they arise from stomach and liver 
exhaustion. I have had lazy, indolent, and ignorant men and women 
come to me with a diagnosis of neurasthenia from mental strain, 
who for years have neither worked brain, legs, or arms, the only 
muscles they have ever tired by exercise having been the masseter ; 
and yet these patients have accepted from physicians, without cavil, 
a diagnosis of nervous prostration, and have been pleased and flat- 
tered with the thought. So, too, with the highly popular disease, 
malaria and malarial cachexia. Many of these malarial subjects are 
suffering from lithaemia, and are cured by the method just mentioned. 
It is true that malaria cachexia often complicates lithaemia, as it does 
other diseases, and the periodic aggravations naturally lead to a diag- 
nosis of malaria, but if we regulate the habits and diet of our mala- 
rial patients T stop their quinine and restore the function of the liver, 
or give nature a chance to do it, the system will be brought to a 
proper level of health, and the malarial poison will be inactive. It 
is to be remembered that it is not by any means certain that the 



DISEASES OF THE DIGESTIVE SYSTEM. 47$ 

periodicity of many of these so-called malarial conditions is owing to 
the presence of the malarial germ in the system. Malarial diseases 
are not the only ones characterized by periodic exacerbations. 

" Next in the order of importance as a factor in the production of 
this disease is the too free use of nitrogenous food, the liver under 
such circumstances being unable to convert the excess into urea. It 
is true that large quantities of meat have been taken with impunity 
by many invalids, and even good results have followed ; but in these 
cases, all articles of diet having a tendency to tax or irritate the stom- 
ach have been excluded, and several pints of hot water have been 
taken daily with the diet of meat, and have probably prevented the 
formation of uric acid or acted as a solvent for it, so that it has not 
accumulated in the system. 

" Then come indiscretions in diet which have a tendency to dis- 
turb the stomach, developing chronic catarrh of that organ and dys- 
pepsia, by which substances are generated in the stomach which, by 
their absorption and passage through the vessels of the liver, poison 
that organ and disturb its function, so that instead of waste material 
being converted into urea, uric acid results, which enters the general 
circulation and is not properly eliminated by the kidneys. It should 
be noted that authorities now agree that there is an uric-acid secret- 
ing function of the kidneys ; if the kidneys are injured by the pres- 
ence of an excess of this material circulating in the blood-vessels of 
their parenchyma or by other causes, changes take place in the renal 
epithelium which result in temporary or permanent loss of the uric- 
acid excreting function. Excessive production, with diminished 
power on the part of these excretory organs to eliminate uric acid, 
necessarily results in a permanent accumulation of the poison in the 
blood. 

" The next, and a most potent, factor in the etiology of lithsemia 
is an indolent, lazy life — even with a diet of mush and milk. For 
the liver to work properly, exercise of the body — and perhaps of 
the mind — is imperative ; if its function is disturbed, lithaemia nec- 
essarily results. 

" Functional Disturbances Resulting from Lithaemia. — With a 
toxic element circulating in the fluids of the body, it is hardly to be 
expected that any of the organs should escape its influences ; and a 
close study of this disease, and a large experience, both in my consul- 



480 THE PRACTICE OF MEDICINE. 

tation and general practice, in the investigation and treatment of 
lithaemia and the organic diseases resulting from it, satisfy me that 
such is the case. The entire nervous system is affected by the pres- 
ence of this poison (lithic acid) in the blood. As was before remarked, 
many of the so-called cases of neurasthenia are cases of lithsemia, and 
can be cured by eradicating this poison from the blood ; and the eti- 
ology of many cases of insanity can be cleared up by carefully con- 
sidering the antecedents of the patients as regards the indiscretions 
of life and hereditary influences, not with special reference to insan- 
ity, but lithaemia, gout, and renal and urinary calculi. 

" The digestive organs always suffer, although the lithaemic patient 
may not be aware of the fact, for in the absence of prominent gas- 
tric symptoms, particularly if the bowels are moved daily, he will 
hardly suspect derangement of the liver function, and that of other 
organs concerned in digestion and assimilation. Prominent, also, 
among the functional disturbances arising from lithsemia are derange- 
ments of the circulatory and respiratory organs, resulting later in 
incurable organic disease. The urinary and genital organs in both 
sexes, in chronic cases of the disease, are rarely exempt from its 
influences. Benal, bladder, and urethral catarrh I have frequently 
found in men and women ; and loss of virile power, with prostatic 
enlargement, is a most frequent accompaniment in the male, and in 
the female, functional disturbances and organic diseases of the gen- 
erative organs occur, while hemorrhoids are common in both sexes. 

" In Fagge's 4 Practice of Medicine,' under the head of Hepatic 
Dyspepsia, may be found Murchison's tabulated arrangement of the 
prominent symptoms of this disease. Bitter or coppery taste in the 
mouth, especially in the morning, intestinal hemorrhage, neuralgic 
pains, feelings of oppression and heaviness, creeping sensations, 
aching pains in the limbs, lassitude coming on after meals, some- 
times accompanied by irresistible drowsiness, severe cramps in the 
legs and in different parts of the body, headache, characterized by 
a dull, heavy pain, seated in the forehead, or more rarely in the occi- 
put, giddiness or swimming in the head, particularly when the 
patient stoops or lays his head upon the pillow, often passing off in 
the erect posture ; tendency to grind the teeth during the waking 
hours, passing off while the patient is asleep ; convulsive attacks, 
simulating epilepsy, are sometimes due to the same cause ; noises in 



DISEASES OF THE DIGESTIVE SYSTEM. 481 

the ears of various kinds, muscce volitantes, sleeplessness, unquiet 
dreams, depression of spirits, irritability of temper, palpitations and 
fluttering of the heart, exaggerated pulsations in the large arteries, 
irregularity and intermissions of pulse, chronic catarrh of the fauces, 
chronic bronchitis and spasmodic asthma, pains in the lumbar regions, 
distension and tightness in the epigastrium after meals, dull aching 
in the right hypochondrium, and sometimes shooting pains in the 
same region ; sense of weight and fullness below the ribs, often 
increased by lying on the left side ; the hepatic region may even be 
sensitive to pressure, pain in the right shoulder, sometimes in the 
left. Often the conjunctivas have a slight yellow tint, and the skin 
may even display traces of the same color. The urine is sometimes 
scanty and high-colored, as it cools depositing large quantities of 
lithates of bright red color. Again, the urine may be clear, large in 
quantity, and of low specific gravity. The bowels may be consti- 
pated or the patients may be troubled with frequent and semi-fluid 
discharges. A common and almost one of the most frequent symp- 
toms of chronic lithaemia is a disposition to urinate during the night. 
It is found, on questioning, that nearly all patients suffering from 
this disease are obliged to rise during the night once, twice, or even 
more frequently, to urinate, not because the accumulation is large, but 
owing, probably, to hyperesthesia of the sensory nerves of the blad- 
der, and to the irritating quality of the urine and its effects either 
upon the walls of the bladder or the nerves of the kidneys. 

" Among the organic diseases known to result from lithasmia, or 
what in this connection is the same thing, from high living — indis- 
creet living — including the long-continued use of alcoholic bever- 
ages, even in small quantities, intemperance in eating, sedentary 
habits, long continued mental strain and worry, may be mentioned 
first and most common, chronic interstitial nephritis, chronic catarrh 
and hypertrophy of the walls of the bladder, chronic prostatitis, 
chronic pyelitis — from the accumulation of lithic acid crystals and 
the formation of renal calculi in the pelvis of the kidneys — stone 
in the bladder, atheroma of the arterial walls in the various parts of 
the body, with its terrible consequences, including hypertrophy of 
the muscular walls of the heart, although this latter condition can 
hardly be called a disease, for in every instance it is compensatory, 
in that it compensates for the narrowing of the calibre of the arte- 

31 



482 THE PRACTICE OF MEDICINE. 

rioles resulting from fibroid changes and obstructions owing to 
atheromatous changes in the walls of the larger vessels, aneurisms, 
large, small and capillary, the latter particularly in the substance of 
the brain, which, by their yielding, result in cerebral hemorrhage, 
the apoplectic attack being sometimes the cause of sudden death, 
valvular disease of the heart and peri-and endocarditis, fatty degen- 
eration of the heart walls — a most common cause of death in lith- 
semic subjects — chronic pharyngeal, laryngeal and bronchial catarrh 
resulting from the latter, pulmonary vesicular emphysema, broncho- 
pneumonia and chronic insterstitial pneumonia or the so-called fibroid 
phthisis, and finally various chronic diseases of the stomach and 
intestinal canal, hemorrhoids and fistula in ano. And I am con- 
vinced from observation of cases which have been under my own 
care that many serious organic diseases of the nervous system result 
from lithsemia. Two cases of progressive locomotor ataxia which I 
have treated have, in my opinion, resulted alone from this cause. 

" In the treatment of lithsemia and the organic diseases resulting 
from an excess of lithic acid in the blood, we sometimes have to 
arrive at a diagnosis by exclusion. There is a cause for every mor- 
bid condition, and there are habits of life, atmospheric influences and 
occupations, which give rise to certain diseases and aggravate them 
if they already exist. 

" The first step towards treatment is to make a positive diagnosis, 
then to see if we can learn the causes of the disease, and to learn 
whether the life of the patient is such as to permit us to labor untram- 
melled with our remedies and measures for his relief. Then we 
should correct the mode of life, if we find need of it, and insist upon 
the patient aiding us by his own efforts to effect a cure, if a cure be 
possible, or to arrest the progress of the disease, if it is of an incur- 
able nature, and thus make his life as comfortable as it can be under 
existing adverse circumstances. 

" If a patient consults us suffering from the symptoms given above, 
or from any of the organic diseases mentioned, we should make care- 
ful inquiries to learn if other known causes exist. If we find they 
do not, on further inquiry we will learn of indiscretions which have 
given rise to or are aggravating the condition, and a careful exam- 
ination will lead us to a diagnosis of hepatic disturbance, by which 
waste material in the blood, instead of being converted into urea, 



DISEASES OF THE DIGESTIVE SYSTEM. 483 

which is readily eliminated, is by imperfect oxidation converted into 
lithic or uric acid, and retained in the fluids of the body. The treat- 
ment is then simple enough : Correct indiscreet habits of life, lay 
out a proper course for the patient to pursue, and help nature by the 
administration of the carefully selected homeopathic remedy. If in 
doubt as to the special mode of life and diet in an individual case, 
advise, on general principles, a life and diet which we know to be 
harmless, as did the pioneers of homeopathy. Professor Small used 
to say to us in the lecture room : 4 Gentlemen, if you are in doubt as 
to the remedy in an individual case give sulphur high. It is a gen- 
eral corrective and can do no harm, and it is more than likely it is 
just the remedy the patient needs.' " 

Treatment. — The same remedies recommended for biliousness, 
are suitable for lithasmia, not because the two conditions are identical, 
but because they are similar. One of these conditions may appear 
alone, but we often find them in the same patient at the same time. 
There are three things to be brought about in treatment : (1) A 
regulation of the diet so that digestion may be perfect, and no waste 
or toxic material carried to the liver. (2) The induction of such 
activity in the hepatic cells that they will oxidize the lithic acid into 
urea. (3) Enough physical exercise to aid digestion and the func- 
tional activity of the liver. These will be quite fully elaborated when 
treating of deficiency of bile and biliousness. 

The chemical treatment of lithaemia is not favored by the more 
conservative in our school, but I do not see how it can interfere with 
the law of similars. 

Our specific medicines will certainly act on the system better 
when the blood and secretions are normal, than when loaded with 
uric acid and the product of deficient digestion and assimilation. 

The use of alkaline waters for the excess of acid need not inter- 
fere with the remedial action of our medicines, which have an action 
deeper and more radical. The selected medicines should correspond 
to the general condition, not to the condition of the urine alone. We 
may cause the lithates and uric acid crystals to disappear from the 
urine, and even render the urine alkaline, but the cause of the lith- 
aemia may remain active and untouched. It is only when the diet, 
habits, regimen, and other causes have been corrected that medicinal 
agents act favorably. 



484 THE PRACTICE OF MEDICINE. 

The chief ingredients of the alkali or alkaline waters should be 
sulphate, phosphate, or bicarbonate of sodium ; of less value are the 
salts of potassium, although the citrate of potassium is often useful. 
When the natural waters cannot be obtained, their salts prepared 
from them by evaporation — as the powdered Carlsbad salts — are 
good substitutes. Nearly all the alkaline salts are made granular 
and effervescent, and are quite palatable. In all cases it is not nec- 
essary to give purgative doses, unless the intestines are loaded with 
mucus and toxic fsecal matters. 

Sir Henry Hamilton considers the sulphate of sodium (natrum 
sulph.) particularly valuable, and he bases his view upon the fact 
that it purges by exciting elimination from the glandular structures, 
rather than by increasing peristalsis or osmosis, as is the case with 
the other saline cathartics. Now in lithsemia, this eliminant action 
is just what is required. If the patient is gross and plethoric, pur- 
gation will be of benefit, but in most cases a slightly laxative effect 
is all that is necessary. During the first twenty years of my prac- 
tice I did not prescribe laxative mineral waters or their alkaline 
salts. When I commenced their use I soon became convinced that 
in the treatment of gastro-intestinal and hepatic disorders, cures were 
effected much sooner with than without their aid. 

The salts of lithium have been excessively lauded by the profes- 
sion and advertised ad nauseam by the owners of lithia springs. I 
have never seen the benefit I expected from the use of lithium waters 
in the general lithaemic state. They sometimes render the urine less 
acid, and, if drank freely, lessen the tendency to the formation of 
uric acid calculi. When the urine is very concentrated, very acid, 
offensive, and deposits a great quantity of sediment, the benzoate of 
lithium has acted well. 

It is asserted by Haig that salicylate and phosphate of sodium 
increase the excretion of uric acid in the urine, and also increase it 
in the blood, withdrawing it from the liver and spleen. He also says 
that acids and iron interfere with the solubility of the acid and with 
its elimination. I doubt the correctness of this assertion, for I 
believe from my observations that fruit acids, and the nitro-muriatic, 
have the opposite effect. He makes another broad statement which 
will shock the belief of the friends of lithium — that " though a beau- 
tiful solvent of uric acid in a test tube, yet when given to the human 



DISEASES OF THE DIGESTIVE SYSTEM. 485 

subject by mouth, lithium never reaches the uric acid at all, because 
it at once forms an insoluble compound with the phosphate of sodium 
in the blood, thus removing from that fluid one of the natural sol- 
vents of uric acid, and diminishing its power of holding uric acid in 
solution." 

However this may be, it warns us to be cautious in allowing 
lithsemic patients to take large quantities of lithium. The lithiated- 
potassium, in small doses, is a favorite remedy with many, but it 
should be cautiously used. Piperazin is a new medicine for which 
much is claimed in the treatment of lithsemia and gout. Dr. Bies- 
enthal lately stated that all observers agree that piperazin is an 
absolutely sure remedy in fresh cases of gout, and that even in 
chronic gout its action almost never fails. The continued use of 
piperazin, even in small doses (fifteen to forty-five grains in a 
week), is a sure prophylactic. Further, the remedy has proved of 
value in all cases of kidney colic, and again in a whole series of 
cases of hemorrhage from the urinary tract. Bleedings that had 
lasted for years have entirely ceased under its use. (Berlin Clin. 
Wochensch.) 

The hydrochlorate is preferred, and it is best administered in 
aerated water. It is said to unite with uric acid in the blood, form- 
ing urate of piperazin. This is seven times more soluble than the 
lithium salt. Piperazin is said to be non-toxic, and not a caustic. 
The dose is from two to five grains every three or four hours in 
acute and every six hours in chronic cases. It would seem to be a 
near analogue of thapsi, according to Dudgeon's estimate of the 
latter. 

Dr. Dowling's favorite remedy in lithsemia was berberis, one of 
the constituents of the root of hydrastis. It is particularly indi- 
cated when the urinary deposits are uric acid crystals, or the amor- 
phous urates, forming a brick dust, or pink sediment ; these are the 
acid sodium urates, and occur when the urine is very acid and of a 
high specific gravity. Berberis is said to act better when given in 
infusion. 

Thapsi bursa pastoris, according to Dr. Dudgeon, causes uric 
acid crystals to disappear from the urine in a remarkably short 
time. The ancients used it for chronic diseases of the liver and 
especially for passive venous hemorrhages. It may be almost spe- 



486 THE PRACTICE OF MEDICINE. 

cific for the hemorrhages occuring from lithsemia, which are always 
venous and passive. 

" Lycopodium," Dr. Hughes says, " I find the very best medicine 
when the patient is suffering from an excess (?) of lithic acid gravel, 
and look upon copious sediments of this nature as one of the most 
unerring indications of its choice in dyspepsia." Dr. Guernsey laid 
great stress on the symptom " red sand in the urine." 

Lycopodium has an undoubted action on the liver. It is indi- 
cated in chronic lithsemia, when the disposition to biliousness, dys- 
pepsia, and excess of uric acid has become fixed in the system ; 
Lilienthal recommends it in chronic hepatitis. I never had any not- 
able success with it, until I began to use the mother tincture pre- 
pared from the crushed spores. These contain an oil, which is the 
real medicinal agent. Now I get all the good results Hahnemann's 
provings led me to expect. 

Sepia is another medicine of great value in chronic lithaBmia. It 
acts especially on the portal system, particularly when the disorders 
of this system occur in women and are connected with diseases of 
the reproductive organs. Baehr and Meyer both recommend it in 
lithaBmia, and Dr. T. F. Allen's provers all noticed a great increase 
in the urates in the urine, which was very acid and of high specific 
gravity. An amorphous whitish or brick-dust sediment was depos- 
ited. Dr. Dunham used it in " sub-hepatic congestion with lithiasis" 
with excellent results. 

The Diet Suitable for Lithcemics. — Starchy and saccharine 
articles of food should be used very sparingly. All meats except 
lean pork, veal, and beef, may be eaten moderately. Eggs, oysters, 
and fish are allowed, but not lobsters or crabs in any form. Sweet- 
bread should not be eaten, but acid fruits, raw, or cooked without 
sugar, are beneficial. Lemonade made with Vichy water, sweetened 
with saccharin, can be taken ad libitum. Alcohol in any form should 
be prohibited. Champagne is especially injurious. A good claret 
is the least injurious. Fresh vegetables may be used. Hot rolls, 
cakes, hominy, oat meal, pies, and cake are not permissible. Zwie- 
bach, granola, wheat germs, and gluten may be eaten. All fats are 
beneficial, especially bacon and butter. Milk, diluted with Vichy or 
seltzer, can be used as a beverage. Black tea moderately, but little 
or no coffee. 



DISEASES OF THE DIGESTIVE SYSTEM. 487 

INCREASED SECRETION AND EXPULSION OF BILE. 

We may have increased secretion of bile without any decided 
manifestation of its presence in the stools. A large portion of it may 
be absorbed, or it may not be secreted in sufficient quantity to irritate 
the intestines to the extent of causing diarrhoea. When there is suffi- 
cient quantity poured into the intestines to cause diarrhoea, the stools 
are yellow, green, or the various shades of these two colors when mixed 
in varying proportions. There may be nausea, griping, and the 
stools, at first normal in color, grow gradually more yellow or green, 
become more liquid with increased griping, and cause a smarting at 
the anus. 

Children are more subject to this disorder than adults, because 
the size of the liver is much greater in proportion, and more sensi- 
tive to impression. The causes are the overeating of meats, highly 
seasoned soups and other mixed dishes, or eating too much of even 
simple food. In health, eating excites temporarily the secretion of 
bile. If too much is eaten the secretion is abnormally increased. 
Hot beverages, hot air, and active exercise has the same effect. This 
disorder commonly occurs during the summer months in temperate 
regions, and in the tropics all the year around. It rarely occurs 
unaccompanied by a catarrhal state of the intestinal mucous mem- 
brane, and often of the stomach. The same influence that increases 
the activity of the liver also increases the activity of the glandular 
elements of the digestive tube. When drugs cause an increased secre- 
tion of bile, it has been noted that an intestinal catarrh is generally 
present. 

Treatment. — It has been shown by the experiments narrated, 
that there are many drugs which have an undoubted influence in 
increasing directly the secretion of bile. They will all cause the intes- 
tinal symptoms mentioned above. There are many more, which have 
not been experimented with by the methods of Rutherford and others, 
that are just as potent agents in their action on the hepatic cells. 

To ascertain which these medicines are, we naturally turn to such 
a work as " Bell on Diarrhoea." He gives as causing bilious diar- 
rhoea only twenty-three medicines. Among them we find aloe, col- 
ocynth, ipecac, leptandra, and mercurius virus, which we find in 
Rutherford's list, and other drugs of which it is difficult to conceive 



488 THE PRACTICE OF MEDICINE. 

why they are placed under that heading. We turn to the " Color of 
the Stools," and find under "green," sixty-four medicines; under "yel- 
low," seventy-five medicines, and nearly as many under " black " and 
" brown." Now why are not all these medicines put under the head- 
ing " Bilious " ? Probably in a large proportion of the cases of black 
and brown stools they were of normal consistency. This will show 
how faulty our repertories are. 

When we select a remedy for a condition diagnosed as increased 
secretion of bile, we must first decide what medicines really have 
that effect. We know that the drugs mentioned in the experiments 
quoted have that effect. We have reason to believe from the prov- 
ings that many others act similarly. Among these may be placed 
agaricus, chamomilla, chelidonium, carduus, and pulsatilla. There 
are many among the yellow and green lists that we do not believe 
have any influence in that direction. 

(1) Some of them by their laxative effect cause the expulsion of 
the bile already in the intestines before it has performed its func- 
tions, or before the absorbents have time to take up the residue. 

(2) It is well known that many of our provings are so faulty 
that they contain the records of attacks of illness which could by no 
possibility belong to the drug proven. Only one example will suf- 
fice. In Savery's proving of asclepias tuberosa he took two drops 
of the tincture, and without repeating the dose recorded all his symp- 
toms for a month (?). On the fifteenth day he had yellow stools with 
griping, etc., which he recorded as a symptom of that drug. Many 
of our provings contain symptoms just as worthless. 

We must discriminate closely then between trustworthy and gen- 
uine symptoms, between those which cause increased secretion and 
those which cause only expulsion of bile. When we have done this 
there remain enough to choose from. We must be guided by the con- 
comitant symptoms attending the characteristic one of " abnormal 
amount of bile in the stools." My personal experience is that mercu- 
rius dulcis, euonymin, podophyllum, iris, colocynth, leptandra, rhu- 
barb, chamomilla, pulsatilla, dioscorea, and a few others are most gen- 
erally indicated. In rare cases unusual medicines are indicated, as 
croton tiglium, gambogia, etc. In cases like bilious diarrhoea, when 
the symptoms resemble the primary effects of these drugs, use the 3x 
dilution of the tincture, or the 6x of the active principle. 



DISEASES OF THE DIGESTIVE SYSTEM. 



489 



One of the best works to consult in this matter is a Repertory 
now being prepared by A. R. McNaughton, M.D. I insert speci- 
men examples of his method : 

COLOCYNTH. 

Stool. — Saffron-yellow; frothy; liquid; 
sour; putrid. 

Aggravation. — After eating; after drink- 
ing; from fruit; during dentition. 

Concomitants. — Intense griping, cutting 
or squeezing in the intestines. Tongue 
white or yellow. Bitter taste. Canine 
hunger. Much thirst. Vomiting of 
bile. Distention of abdomen, with 
rumbling. Weakness, paleness, and 
great prostration after stool. Cut- 
ting colic, with great urging before 
stool, relieved by bending double. 



Podophyllum. 

Stool.— Greenish ; watery ; profuse ; gush- 
ing; painless. 

Aggravation — In morning; at night; 
during hot weather; after milk and 
acid fruit together; after eating and 
drinking; during dentition. 

Concomitants Prolapsus ani. Exhaus- 
tion. Rolling of the head during 
dentition. Tongue coated yellowish 
or white. Loss of appetite. Desire 
for acids. Gagging or empty retch- 
ing. Violent cramps of the calves, 
feet, and thighs. 



Chamomilla. 

Stool Chopped, white and yellow mu- 
cus; slimy; hot; small; frequent; 
smelling like bad eggs; yellowish, 
watery. 

Aggravation. — During dentition; after 
taking cold; after anger; at night. 

Concomitants Peevishness. Ill hu- 
mor. Children cry much and are 
only stilled by being carried about. 
One cheek red and the other pale. 
Tongue yellow or white. Bitter, sour 
taste. Aversion to food. Intense 
thirst. Sour vomiting. Abdomen 
hard and distended. Moaning in 
sleep. Sticky sweat on forehead. 

Mercurius. 

Stool. — Dark green; bilious; frothy; 
watery with greenish scum floating on 
the surface of the water; mucous; 
slimy; scanty; corrosive; sour smell- 
ing. 

Aggravation. — From cool evening air; 
at night; in hot weather; during den- 
tition; in cold damp weather. 

Concomitants Violent tenesmus and 

continued urging. Prolapsus recti. 
Face pale. Tongue swollen showing* 
imprint of teeth on edges. Profuse 
salivation. Offensive breath. Per- 
spiration on the least exertion. Of- 
fensive or sour-smelling night-sweat. 



Diet and Regimen. — The patient with excessive secretion of 
bile should keep his body cool, drink cool drinks, eat no meat or 
fats, but farinaceous foods well cooked, with tea or skimmed milk, 
and fish or young chicken. When there is excessive expulsion of 
bile the symptoms are sudden diarrhoea after the expulsion, or even 
before, of the faecal matters, the stools become profuse, with severe 
griping. Sometimes nausea and vomiting of bile attend it. This 
affection may arise from a sudden catarrh of the bowels, from 



490 THE PRACTICE OF MEDICINE. 

fright, a chill while overheated, or the rapid fermentation of food. 
Or it may be caused by the sudden discharge of an overloaded gall- 
bladder, the duct having been closed by catarrh, spasm, or a gall- 
stone. Usually the diarrhoea subsides spontaneously when it arises 
from the latter cause. The remedies best indicated in this form of 
the disorder are gambogia, croton tiglium, colocynth, iris versicolor, 
cinchona, podophyllum, and others selected according to the special 
indications. 

Dr. Goode, in writing of Headache, mentions a peculiarly severe 
variety of bilious headache, which suddenly terminates, " as soon as 
the patient feels as if something gave way in the region of the liver, 
followed almost immediately by a violent diarrhoea of almost pure 
bile." This is an example of the form of bilious diarrhoea above 
mentioned. 

Some authors mentioned another disorder under the name of 
" Secretion of vitiated bile." But the latest investigations into the 
composition of the bile show that it is always aseptic, and never 
becomes vitiated unless during the progress of some malignant fevers 
or in infective jaundice. 

BILIOUSNESS. 

Deficient Secretion and Excretion of Bile. — The term bilious, 
which is now ignored by scientific pathologists, has fixed itself so 
deeply in the minds of both physicians and laymen, that a work on 
diseases of the liver cannot be written without some recognition of 
it. Biliousness is not a disease of itself, but is made up of three 
conditions generally present in greater or less degree in nearly all 
cases. 

Gastric Catarrh. — This condition has been treated of in another 
chapter. In acute cases the hepatic complication is not always 
present, but in chronic gastric catarrh the functions of the liver are 
always interfered with. Unless there is an irritative catarrhal con- 
dition of the duodenum, the condition of the liver is one of func- 
tional torpor. The hepatic cells do not do their proper work in 
destroying albuminoid matter and the elimination of urea ; or if the 
catarrhal affection has invaded the ducts, the excretion of bile is 
mechanically prevented. In such cases the bile is absorbed into the 
blood and poisons nearly every organ of the body. There is but a 



DISEASES OF THE DIGESTIVE SYSTEM. 491 

short space between jaundice and a severe attack of biliousness, for 
in nearly all cases of temporary deficiency of bile there is a slight 
icteric hue of the skin — the " muddy," sallow discoloration so well 
known to physicians. 

The typical symptoms of an attack of " biliousness " are head- 
ache, occipital or frontal, drowsiness during the day, and heavy 
sleep at night, or sleeplessness ; the patient is melancholy, morose, 
and irritable, there is nauseating phlegm in the fauces, and disgust 
for food, or a sensation of sinking in the stomach which impels one 
to eat ; or a heaviness in the stomach as of a " load " there. After 
eating there is headache, sour eructations, pyrosis, water-brash, and 
drowsiness with flushed face. On waking in the morning the patient 
does not feel rested, there is a bitter or metallic taste on the tongue 
which is coated yellow or brown. The abdomen feels distended, the 
clothing feels tight when it is not. The bowels are sluggish, and 
the stools are hard, lumpy, blackish, or gray ; the urine may be pale, 
— or dark with high specific gravity. 

Nearly all these symptoms may be also seen in lithaemia and 
gastric catarrh. 

Having considered Lithaemia in a previous chapter, I will give 
my experience as to the various medicaments for biliousness or defi- 
cient secretion and excretion of bile, together with the hygiene and 
diet most suitable to aid in removing that condition. 

Those medicines which in large doses cause an abnormal increased 
secretion and excretion of bile are indicated in biliousness, for the 
reason that the opposite condition is the result of their secondary 
action. This is according to the law of similia. The dose should 
be so small that no reaction or secondary symptoms will follow. 

Mercury in some form has been considered the chief remedy for 
biliousness. It is or has been generally prescribed in large doses, 
:five to ten grains of calomel, or three to five grains of blue mass. 
But the tendency in the regular school is now constantly towards 
smaller and repeated doses, for as their best and most recent author- 
ities express it, large doses, while they seem to relieve promptly, are 
followed by increased torpor of the hepatic functions, and the liver 
becomes less and less susceptible to its influence. 

The two best preparations of mercury for the bilious state, 
described above, are undoubtedly mercurius dulcis (calomel), and 



492 THE PRACTICE OF MEDICINE. 

mercurius vivus, or " massa hydrargari " (blue mass). Blue mass is a 
trituration of mercurius vivus with conserve of roses, the mercury 
forming one-third of the mass. When the symptoms mentioned 
above are present — and they can all be found under mercurius — 
the 2x or 3x trituration, in doses of three to five grains repeated every 
three hours, will soon dissipate all the symptoms. There are some 
exceptions to this, namely : when the patient has been in the habit 
of taking larger doses of mercury or other cholagogue drugs, and his 
liver is torpid from over-stimulation ; then if mercury is better indi- 
cated than any other medicine the dose may be increased to a few 
grains of the lx. I know not why it is so, but I have met many 
instances where no other apparently indicated medicine had any 
decided influence over the condition, which was not removed until 
one or two grains of blue mass were given at bedtime, and followed 
the next morning with a laxative dose of Congress or Rubinat water, 
or a seidlitz powder. The axiom of some of our school, that if the 
lower attenuations do not act well we must go higher, is not true in 
hepatic torpor, however it may be in more sensitive organs. This 
is also the opinion of Dr. W. H. Holcombe, of New Orleans. 

Ox-gall is next to mercury in its efficacy, for not only does it 
somehow increase the functional activity of the hepatic cells, but it 
supplies bile to the intestines, when in biliousness the bile is defi- 
cient. It is particularly indicated when the bowels are sluggish, the 
stools gray or dry and hard. One grain before each meal and at 
night is sufficient. They are prepared in pills, sugar-coated. 

Euonymin is perhaps the most certain and satisfactory of all. It 
is not an irritant to the stomach, duodenum, or intestines. It is 
indicated in deficient secretion, with gastric catarrh and lithaemia ; 
also in the decided indigestion which obtains in the stomach and 
intestines. Intense, heavy, wearing occipital headache is the chief 
characteristic symptom. The bowels, neither loose or constipated, 
are generally regular, but the stools are usually deficient in bile. 
After the administration of one-grain doses of the lx or 3x tritura- 
tion three or four times a day, the headache and anorexia will leave ; 
the stools become yellow, and often large quantities of yellow mucus 
will pass the bowels. 

Leptandrin has a sphere of action peculiarly its own. It causes 
in large doses alvine discharges of a black, tarry substance, and when 



DISEASES OF THE DIGESTIVE SYSTEM. 493 

given in disease, the discharge of this matter is usually followed by 
improvement. The same fact has been observed after the adminis- 
tration of mercury, especially mercurius dulcis. It was once sup- 
posed that this black, tarry material came from the gall-bladder and 
was a thickened, vitiated bile. This may be true in some cases, as 
when the gall-duct has been obstructed, but this black substance is 
generally formed in the colon. The ancients associated the presence 
of this substance with melancholy and a desire for death, and such is 
frequently the case. Dr. Henry Holland, in his " Memoirs," men- 
tions this condition, and observes that the liver may not be the 
cause of this secretion. Certain it is that it is a poisonous product, 
probably of decomposition of food, or secretion of the colon, and its 
retention causes very serious symptoms, mental and cerebral. Lep- 
tandra may possibly cause a morbid condition favorable to the forma- 
tion of this product, or it may simply have the power of expelling it 
when present. I should consider it indicated, and give the lx, sev- 
eral grains every three or four hours in case of melancholia with indif- 
ference to life, when met with in biliousness, and I have given the 2x 
when the stools were black and " tarry," with excellent results. 
These black stools indicating mercurius and leptandrin should not 
be mistaken for the black stools composed of disorganized blood, 
occurring in hemorrhage from the veins of the portal system ; but 
even in this case leptandra may be useful. 

Iris versicolor and its active principle, iridin, was a valued medi- 
cine among the aborigines of this country. It was considered by 
them the best of all " spring medicines." A decoction was made of 
the roots and drank until it vomited and purged. It was used much 
as veratrum album was used by the ancient Greeks. Our native 
Indians drank it before going to war, or engaging in athletic sports, 
in order " to clear the brain and the stomach from morbid matters." 
In large doses it causes an increased flow of thin, yellow bile, with 
vomiting of bile and diarrhoea of the same. When these primary 
effects are over the liver becomes torpid and secretes less than nor- 
mal, and as a result the secretions of the stomach and intestines 
become acid and irritating, with indigestion and severe frontal head- 
ache, attended by nausea and vomiting. In this it resembles Pulsa- 
tilla and rheum, except that the latter does not cause headache to 
the same extent. Its secondary symptoms make it indicated for the 



494 THE PRACTICE OF MEDICINE. 

so-called bilious and acid sick-headache. The pain in the head is 
over the eyes and in the temples. It is often difficult to differen- 
tiate between the biliousness and sick-headache of iris and pulsatilla. 
The lower attenuations for the secondary symptoms act best ; for 
the primary bilious diarrhoea and vomiting, the sixth is often found 
promptly curative. . 

Sanguinaria and chelidonium are excellent remedies for bilious- 
ness. Belonging to the same botanical family, they have the same 
constituent active principles — sanguinarin and chelidonin. The 
headache of sanguinaria begins in the occiput, ascending from the 
nape of the neck along the right side of the head to the right eye ; 
the pains shoot from the occiput through to the ears, or commence 
in the temples and extend to the right eyes, and are periodical. There 
is nausea, with congestion of the liver, pains under right clavicle, 
portal congestion, tongue feels as if scalded, bitter taste, aggravated 
by the slightest noise, stooping or motion. The biliousness of san- 
guinaria is often caused by a catarrhal state beginning in the head, 
extending to the stomach and bronchi, and ending in diarrhoea which 
relieves all the symptoms. The gastric catarrh is attended by burn- 
ing in the throat and stomach — a kind of pyrosis. The biliousness 
of chelidonium is very similar. There is some congestion of the 
liver and portal system. The headache is also in the occiput and 
extends along the right side of the head to the eye ; it is periodical 
and may be exaggerated at 11 A. M. The vomiting is rare, but 
there is nausea, the tongue is narrow and pointed, the taste bitter. 
There are severe stitches in the liver, at the right scapular region. 
Both drugs cause increased flow of yellow bile, but chelidonium 
seems the most active hepatic stimulant. When the secretion of 
bile is suppressed, ten to fifteen drops every four hours of the tinc- 
ture will restore it, and relieve the head and gastric symptoms. In 
bilious diarrhoea, the 3x dilution is sufficient. Both are useful when 
the hepatic torpor seems to affect the right lung, causing cough and 
some expectoration. They are useful in the so-called bilious pneu- 
monia. 

Chionanthus, an indigenous remedy, resembles euonymus and 
leptandra. It is not an active purgative, but it seems to cause a mild 
stimulation of the hepatic cells. Like leptandra and calomel it expels 
the black, tarry, secretion from the colon. It has lately been found 



DISEASES OF THE DIGESTIVE SYSTEM. 495 

of value in bilious sick-headache, with yellow coated tongue, nausea, 
and complete anorexia. Nux vomica is a favorite remedy for bilious- 
ness. It is now used by both schools, and probably when not really 
indicated. It is not a cholagogue, for according to Eutherford it 
arrests the secretion of bile when given in large doses. If so, it 
must act on the nerves supplying the cells as a paralyzer, or it 
may act by causing contraction of the hepatic ducts. The bilious 
symptoms of nux vomica are f amilar to all ; the dull, stupid head- 
ache with vertigo, yellow tongue coated at the base, dry mouth and 
fauces, heartburn, water-brash, bitter, foul taste, bitter eructations, 
weight and oppression in the stomach, constipation with frequent 
desire for stools, or scanty watery diarrhoea ; moroseness and irrita- 
ble temper — all point to a torpid condition of the secreting cells of 
the liver, a gastric catarrh, and lithaemia. When the above leading 
symptoms are present nux vomica, lx to 6x according to the sensi- 
tiveness of the patient to its action, will remove all in a few days. 
Should these symptoms be brought on, as they sometimes are, by 
anger or vexation, chamomilla in appreciable doses of the tincture 
will soon remove them. It is an excellent remedy for the bilious- 
ness of nervous, irritable women and children. 

Bryonia has a reputation equal to nux vomica, but the conditions 
differ. The biliousness of bryonia is like that found in rheumatic 
subjects, and occurs generally during the damp and cold or damp 
and hot months. I have found it particularly useful when it occurs 
after an attack of profuse diarrhoea, or after active purgation from 
drugs. Aloe is one of our best remedies for a bilious state, when 
torpor of the portal system is the chief pathological condition. This 
means passive congestion of the liver and hemorrhoidal vessels. 
There is a feeling of distension in the hepatic region and abdomen, 
a bitter taste, a sickly, sallow face, and some jaundice. These are 
secondary symptoms and require doses of one-hundredth to one-tenth 
of a grain, repeated three or four times a day. The action of aloe 
has not been fully understood by any school. Primarily, according 
to Rutherford and other experimenters, it causes a profuse flow of 
green bile, with large but not thin evacuations, yellow, green, or 
greenish brown, with bloody mucus of a strong odor of bile, and 
burning in the rectum. The secondary symptoms follow soon after. 
The active congestion of the liver and portal system is followed by 



496 THE PRACTICE OF MEDICINE. 

a passive stagnation of the circulation in the liver and whole venous 
system, resulting in a typical bilious hemorrhoidal state. The fear 
that material doses of aloe will cause an aggravation is unfounded. 
If we are treating symptoms similar to its primary effect there are 
grounds for this fear of aggravation ; no one would dare to prescribe 
larger doses than the 3x trituration in such acute irritation of the 
liver and intestinal canal. But when the secretions of the liver are 
locked up, the portal and hemorrhoidal veins engorged, and the circu- 
lation sluggish, the dose must be large enough to arouse a functional 
activity without causing primary effects. The biliousness simulating 
that of aloe is unusually met with in men and women past the mid- 
dle age — at the " change of life " — for both sexes change. In such 
the venous blood is far in excess of the arterial. I have found that 
in order to remove the intestinal torpor, the obstinate constipation, 
the swollen hemorrhoids, the passive congestion of the head, liver, 
and in fact, all the organs, the dose of aloe should be one-fourth to 
one-tenth grain ; or of aloin, from the one-tenth to the one-hun- 
dredth. These doses repeated every four or six hours will in a few 
days effect a complete change in the abnormal state of the patient. 
I have never seen the slightest aggravation from such doses of aloe. 
Dr. Tilt, in his admirable work on the " Change of Life in Women," 
goes further, and advises laxative doses (one or two grains of aloe 
every night), declaring that he has cured old, obstinate hemorrhoids, 
with portal congestion, cerebral congestion, and obstinate biliousness, 
with such doses, and asserts that he never observed any aggravation 
from its use if the medicine was suspended when improvement was 
obtained. 

Carduus closely resembles aloe. It stands between that drug and 
hamamelis in its action on the veins. We know but little of the 
general physiological effects of hamamelis. It may act on the liver 
and portal system as it does on the veins of the rectum and the 
lower extremities for aught we know. Carduus acts upon the circu- 
lation in the liver and portal system, as we do know. (Hamamelis 
acts upon the veins in other portions of the body.) It also acts 
similarly to chelidonium, sanguinaria, chionanthus, and euonymin. 
During the grippe, I found it specific for the bilious, gastric state 
resulting from that disease. It was used in Germany many years 
ago for the "gastric catarrhal condition attending epidemic influenza." 



DISEASES OF THE DIGESTIVE SYSTEM. 497 

A common symptom of biliousness, and one that created some 
alarm to the patient, and is often misunderstood by the physician, 
is a slowness and irregular intermittance of the heart's action and 
pulse. Some experiments made by Rohrig ("Archiv. fur Heil- 
kunde," 1863, p. 385) showed that the bile acids paralyzes the heart 
and retard its action, while bile pigment has no such effect. The 
bile acids according to Legg act on the ganglia of the heart (not 
through the pneumogastric), causing slow intermitting pulse, and 
finally increases the blood-pressure. Murchison, commenting on this 
says, "It is possible, then, that the slowness and intermittence of the 
pulse may be caused by the presence in the blood of the unchanged 
bile acids, even in cases where there is no jaundice ; but more prob- 
ably the cause of the intermission is some other product of albumin- 
ous disintegration, inasmuch as it is so commonly met with in con- 
nection with lithsemia or gout, and as it is entirely removed by blue 
pills, saline aperients, alkalies, and attention to diet. A notable 
fact in these cases is that the tendency of the pulse to intermit is 
usually greatest when the patient is at rest, and diminishes or ceases 
on taking exercise." This is a valuable diagnostic sign. I have 
observed it frequently in my own person, and in many of my patients. 
If you are in doubt whether the heart or liver is to blame, ask your 
patient to walk briskly for a minute. If the intermittence is hepatic 
it will apparently disappear. Connected with this slowness and inter- 
mittence there is sometimes vertigo and palpitation. 

In selecting the remedy for this condition, if the heart is not 
weakened by its long continuance, some hepatic remedy must be used. 
The medicines which correspond to this condition are mercury, 
euonymin, podophyllin, and nitro-muriatic acid. These drugs by 
their secondary action so paralyze the hepatic cells that they cease to 
excrete the bile acids. These acids are not secreted from the blood, 
says Legg, in his great work on " The Bile," but are manufactured 
in the liver ; but when the liver fails to excrete them they with other 
bile constituents get into the blood and poison it. The medicines 
above mentioned favor the excretion of the bile acids when given in 
doses sufficient to cause their normal physiological action — not their 
pathogenetic. It should be remembered that any weakness of the 
heart, functional or structural, resulting in decreased blood-pressure, 
will lower the activity of the hepatic cells. This will prevent the 

32 



498 THE PRACTICE OF MEDICINE. 

cells from secreting normal bile, and the destruction of the toxic pro- 
ducts carried to them. When this condition obtains, medicines which 
increase the tonicity of the heart may alone remove the biliousness 
and lithaemia. But if the liver was the first to be deranged, and the 
cardiac weakness was a result, then both hepatic and cardiac reme- 
dies should be used. 

Mercury is the most effective ; I have tested it thoroughly in my 
own case and others. When there are the general symptoms of bilious- 
ness, headache, foul breath, yellow tongue, loss of appetite, pyrosis, 
excess of mucus in the fauces and stomach, and constipation, and I 
observe on sitting down or lying that the heart intermits, and beats 
slower than usual, then I know there is deficient elimination of bile 
acids. I usually try first small doses, one-hundredth or one-thou- 
sandth grain of mercurius, podophyllin, or euonymin, which will 
generally remove the symptoms in a few days, but they sometimes 
fail, and larger doses are required. In my own case and a few others 
I am obliged to resort to one grain of blue mass taken at night, fol- 
lowed in the morning by a laxative of Kubinat or Congress water. 
A curious fact is, that sometimes this fails, when a pill compounded 
of blue mass one grain, with podophyllin one-fourth grain, will bring 
about the desired result. After this pill no laxative is needed, 
for the podophyllin will carry off the contents of the bowels suffi- 
ciently. Before you give material doses of mercury ask your patient 
if he has ever been salivated by abuse of the drug. If not, any sin- 
gle dose will not salivate ; but if he has, even the 3x may salivate. A 
case is on record of a person, previously poisoned by this drug, sali- 
vated by mercurius corrosivus 30th. 

Podophyllin has in its pathogenesis all the cardiac symptoms 
usually caused by biliousness. It is chiefly indicated, also, by the 
presence of piles, constipation, distension of the bowels, and colon- 
flatulence. Give the 3x, and if no improvement is observed in a few 
days the 2x. As in using mercury, you may, in torpid subjects, be 
obliged to resort to the lx, two or three grains at night. 

Euonymin in large doses is a cardiac poison, according to Ger- 
man experimenters. I have never seen their experiments, and can- 
not decide whether it is a direct or indirect poison. But I know it 
is an efficient remedy in cardiac disturbance, in inaction of the excret- 
ing functions of the liver. It should be prescribed as directed for 



DISEASES OF THE DIGESTIVE SYSTEM. 499 

podophyllin, but it is a less active medicine, and in case a physiolog- 
ical dose is required, one grain at night is necessary. It is not lax- 
ative in this quantity, and a dose of aperient salts should be taken 
the next morning. 

Nitro-muriatic acid has for a long time held a prominent place 
among the hepatic remedies. It is not indicated in acute cases when 
the liver and stomach is deranged from overeating or exposure to 
catarrhal miasm, but is more adapted to the hepatic torpor and gastric 
catarrh common in hot and damp climates, and aggravated by meat- 
eating, and the use of alcohol. In India and England it is most 
highly valued in chronic cases. It is well known that nitric acid is 
a close analogue of mercury, causing a similar action on the gastric 
and hepatic glandular elements. The union of the two acids seems 
to modify the action of both. Muriatic acid has no known action 
on the liver, but it has a decided tonic action on the glands of the 
stomach and intestines, and is one of the most important constit- 
uents of the gastric juice. Our provings of nitro-muriatic acid are 
of little importance, and give no clue to the valuable clinical results 
obtained from its use. H. C. Wood says that in large doses it 
causes " violent bilious diarrhoea," which shows that it is secondarily 
indicated in hepatic torpor. I have used it extensively and no med- 
icine gives me better satisfaction. 

The testimony of Dr. Scott, of Bombay, and Prof. H. C. Wood 
substantiates my high estimation. They say, " In the chronic hepat- 
itis of hot climates it has been used with great success by Annesley, 
Martin, and other famous India surgeons. The remedy would 
seem not to be indicated in hepatitis with high fever and a tendency 
to rapid suppuration, so much as in the slower form of the affection, 
which normally ends in chronic enlargement and induration of the 
viscus. In the habitual congestion of the liver occasionally seen in 
this climate I have used it with the most marked benefit. In the 
still milder affection known as 4 biliousness,' the pathology of which 
is probably a torpid condition of the small glands of the alimentary 
mucous membrane as well as of the liver, nitro-muriatic acid has 
yielded in my hands most excellent results. That the remedy does 
act upon the liver is proved by the fact that in these cases it some- 
times produces violent bilious diarrhoea. When jaundice depends 
upon obstruction, or upon any of the severer organic diseases of tho 



500 THE PRACTICE OF MEDICINE. 

liver, the acid is of little if any use ; when, however, the jaundice 
depends upon the torpor of the liver, or even when it is catarrhal in 
origin, the remedy may be of great service. Even in the early 
stages of cirrhosis, while the liver is still enlarged, nitro-muriatic 
acid should be tried, as in some cases apparently of this character 
great benefit has been derived from its use." In those forms of 
chronic diarrhoea in which the disease is really an intestinal dyspep- 
sia, nitro-muriatic acid may be of the utmost service, benefiting and 
even curing cases that have resisted other treatment. As the effect 
of the acid is not a sudden one, it is evident that it acts in these 
cases not as an astringent, but by restoring the normal digestive 
power. There is a morbid condition, probably dependent upon 
defective primary assimilation, in which the chief symptoms are gen- 
eral malaise, a feeling of weakness, a lack of elasticity, and a very 
great depression of spirits, in which crystals of oxalate of lime are 
generally to be found in the urine, and in which nitro-muriatic acid 
produces in a few days a surprising revolution." 

Rutherford's experiments show it to be a true cholagogue. This 
preparation should be made as follows : mix three parts of nitric 
acid with five parts of hydrochloric (muriatic) acid in an open meas- 
uring glass, adding them together slowly. An irritating vapor will 
arise. When this has ceased put the mixture into a dark glass bot- 
tle. When prescribed make the lx dilution with distilled water. 
The dose is ten to thirty drops in a wine-glass of water, and may be 
taken through a straw or glass tube if the teeth are sensitive to its 
action. This dose should be taken before each meal. If nux vom- 
ica is indicated give a dose of that medicine after meals. With 
these two medicines, aided sometimes by a dose of pepsin with the 
meals, I have cured many cases of intractable bilious dyspepsia. 

The following medicines should be consulted as they may all be 
indicated: agaricus, baptisia, aesculus, eupatorium perforatum, ipe- 
cac, phytolacca, juglandin, and hydrastin. 

Dujardin-Beaumetz values phytolacca highly. Hydrastin we 
know is almost specific for chronic catarrh of the stomach, with 
indigestion. When hepatic torpor is added this remedy is doubly 
indicated. 

Mineral Waters. — Many cases of chronic biliousness, lithsemia, 
and gastric catarrh will not improve while the patients are at home and 



DISEASES OF THE DIGESTIVE SYSTEM. 501 

attending to their vocations. They will not conform to the proper 
dietary rules. Such patients derive great benefit from a visit to 
mineral springs containing sulphate of sodium, phosphate of sodium, 
and chloride of potassium. These salts, according to Rutherford, 
cause in dogs an increase of the secretion and excretion of bile ; sul- 
phated magnesium (Epsom salts), on the contrary, caused a decrease. 

Many springs of Europe which have a reputation in this condi- 
tion under consideration contain all of the above salts. The springs 
of Carlsbad have the greatest popularity. Carlsbad salts in powder 
form is now considered the best. It contains the most important 
ingredients of the natural water, and can be taken in teaspoonful 
doses dissolved in hot or cold water one-half hour before breakfast. 
Marienbad, Pullna, Rubinat, Vichy, and some of the Hungarian 
springs are held in high esteem. Hungarian water contains too much 
sulphate of magnesium, and I have never seen as good effects from 
it. The United States of America abounds in mineral springs, every 
state in the Union possessing valuable waters. Those which are 
advertised with the most fulsome praises are the least valuable. 
Many of the latter have no other merit than that they are pure ; the 
mineral salts in them being very minute in quantity. We have none 
that quite equals Carlsbad, Rubinat, Pullna, Yichy, or Seltzer. But 
we have many of a similar character, such as the Hathorn, Vichy, 
and Carlsbad, of Saratoga ; the springs of Michigan and Indiana, 
and the numerous springs of sulpho-saline waters in Virginia and 
Pennsylvania. California, Arizona, Colorado, and all the far west- 
ern states abound in springs possessing valuable medicinal qualities. 

It is not generally known that in 1886 our government published 
a list of the mineral springs of the United States, with their analy- 
ses, made by competent chemists. This can be obtained from the 
government printing office for a nominal amount. 
~. All salts above mentioned are indicated by the law of similia. 
We have provings of nearly all of them. These provings and Ruth- 
erford's experiments show that they primarily irritate and stimulate 
the functions of the hepatic cells, and produce a catarrhal state of 
the stomach, bowels, and gall-duct if taken in massive doses. When 
these primary symptoms are present in a patient (e. g., the bilious 
diarrhoea of phosphate of sodium) the 3d and possibly the 6th atten- 
uation will act curatively. But if the opposite condition obtains, 



502 THE PRACTICE OF MEDICINE. 

deficiency of bile with acidity of all the secretions, it must be given 
in large doses — twenty to thirty grains after meals. I have tested 
the 6th for this condition in children, but never found it to be of 
benefit. 

I will add, en 2^ssa?it, that I do not accept the doctrines of 
Schuessler. It is not homeopathy, and I doubt if it be scientific. 
If Hahnemann were alive he would doubtless denounce it, as he did 
the chemico-therapeutics of his day. Any benefit accruing from 
their use is based on the fact that they act according to the law of 
similia. When prescribed for their secondary action, namely : jaun- 
dice, hepatic torpor, enlargement of the liver, and chronic gastric 
catarrh, material quantities, such as are found in the natural waters, 
are necessary to bring about a cure. But the use of these waters 
must not be carried beyond the physiological limits. The physicians 
of both schools at the springs of Europe, after examining patients, 
prescribe the quantity to be drank during twenty-four hours, and 
watch the effects as we do the action of drugs. Patients are not 
allowed, as they are in this country, to drink medicinal waters at 
their pleasure. The diet, regimen, exercise, and habits are all reg- 
ulated by the medical adviser. This aids the cure, and is equally as 
important as the water. 

Exercise is of great benefit to sufferers from chronic biliousness 
and lithsemia. The victims are generally those who lead a sedentary 
life, do not exercise their muscles, breathe shallowly, and eat too 
much. Such patients should be made to walk over hills if possible, 
ride on horseback, breathe deeply (which increases the functional 
activity of the liver) use dumb-bells, Indian clubs, hunt in the 
woods, and walk to their business instead of riding. In chronic 
cases a free, constant open-air life, in the country by the sea, or on 
the hills where an abundance of oxygen can be taken into the sys- 
tem, is absolutely necessary to a cure. 

Diet. — The amount of food taken into the system should be no 
more than equal to its demands. All bilious patients eat too much. 
The advice of Dr. Bence Jones is very applicable : " A minimum of 
albumin in our food should be taken in order to produce the least 
uric acid ; and a minimum of carbonaceous food, in order to allow 
the uric acid to be oxydized as much as possible." 

Dr. Fothergill gives in a very practical way the following advice 



DISEASES OF THE DIGESTIVE SYSTEM. 503 

relating to diet. After explaining the nature of the condition known 
as biliousness, he says : 

" With bilious persons it is well to reduce the amount of food 
taken to the body needs, or as near this as can be attained. And 
especially is the moderation to be practiced as regard those nitro- 
genized elements of our food from which, obviously, the bile acids 
are derived. Bilious persons, then, should avoid the solid joint at 
meals. Joints, chops, and steaks, indeed lean meat in every form, 
must be taken in very small quantities, if at all. Fish, as a less 
concentrated form of albuminoid material, is to be preferred to flesh. 
Vegetables should be largely eaten. Fruits do not disagree. Eggs 
and milk have an evil reputation for encouraging biliousness. Fatty 
and sugary matters are reputed to be bilious ; but if this be so (and 
the view has a basis of fact) it must be indirectly and not directly. 
If the readily oxidizable hydro- carbons attract the oxygen of the 
body, the less oxidizable albuminoids will be left over, the ashes or 
cinders of the body-combustion. Farinaceous matters and vegetables 
should form the staple dietary, accompanied by a certain amount of 
fat ; the amount varying with the season, climate and locality. In 
temperate climates a certain amount of the concentrated fuel food, 
the hydro-carbons, may be required. In tropical countries the diet- 
ary consists of carbo-hydrates only, with advantage. The gastro- 
nomic proclivities may, however, go in another direction but reason 
must be brought to bear upon them. The bilious person should 
avoid the eggs in the traditional breakfast bacon and eggs, taking 
the fat of the bacon by preference. Then if there should be any 
fish, some of it should be eaten. In summer some lettuce or salad 
should be added ; in winter some fruit, especially the apple. There 
exists no real objection to some cream and sugar being added to the 
tea and coffee. Then the lunch should consist of some soup or fish 
with well mashed potatoes or other vegetable, and 4 pulled bread ' 
or biscuits. Dinner should consist of some fish or chicken, a vege- 
table course, milk pudding, and biscuit and butter. Such was the 
dietary on which a gentleman whose liver gave him much trouble 
got well, after being under several physicians of repute without 
avail. On his usual dietary, which embraced a considerable quan- 
tity of lean meat, he grew worse and lost flesh. This is a common 
story. When the liver cannot carry on the proper metabolism 



504 THE PRACTICE OF MEDICINE. 

of proteids into the seruin-albunien of the liquor sanguinis, but 
breaks them down into bile acids or urine solids, the tissues go 
unfed. In fact the albuminoids consumed ' go to feed the disease 
and not the patient,' to use an old-fashioned and time-honored 
expression now getting lost sight of too much. Of course it is well 
to raise the tone of the liver by resort to hepatic stimulants at the 
same time. But by reducing the demand upon the liver as regards 
its function of dealing with albuminoids it can perform its work, and 
normal metabolism goes on. The consequence is the body is once more 
fed and the biliousness is relieved, i. e., the proteid matter is going 
to its wonted destination, the tissues, and less bile acids are formed. 

" Recently a well-known writer of fiction came under my care 
with a tongue covered with a thick fur deeply stained with bile, and 
lithates in her urine. She too had been losing flesh and getting 
worse on a meat dietary with some alcohol, the proper dietetic means 
to get strong in popular belief. She adopted my suggestion, with 
quick and prompt relief, and got well most satisfactorily. When 
the liver is out of order the ordinary dietetic means for getting 
strong are rather mischievous than useful. It is not what is swal- 
lowed but what is digested that is the question. Primary digestion 
goes on in the alimentary canal, and secondary digestion or elabora- 
tion is performed by the liver. Food may be taken and digested, 
but if the elaborating action is defective, nutrition fails, just as much 
as if food were withheld in the first place. When the body is 
starving from liver inadequacy, to force down liberal quantities of 
generous food is to overtax the liver and to hamper its action still 
further. Food rich in carbon-hydrates, and containing but a small 
proportion of albuminoids, is that which is really indicated and 
required. The appetite may be feeble and capricious, the palate 
may be dainty and have its preferences ; these may be met, but after 
all the function of the liver must be remembered ; and with it the 
true body-needs. 

" This is all rank heresy in the opinion of the people at large. 
When a person is below par, plenty of animal food and good wine, 
tonics with iron, are the things to get him up certainly in most cases ; 
but when the liver is involved there is an error in the equation. So 
long as the liver is competent to its work, so long the equation is 
correct ; but when the liver is unequal to its work this regimen but 



DISEASES OF THE DIGESTIVE SYSTEM. 505 

further embarrasses it. The number of stories told one of the failure 
of this plan to get strong, by different patients, is conclusive. A 
number, too, furnish some curious corroborative testimony. They 
bring a specimen of urine for examination in a bottle ; and not infre- 
quently the bottle has on it in raised letters ' Quinine and Iron 
Wine.' It has signally failed in their cases. A look at the tongue 
and a few well-directed questions soon lighten the matter up ; and 
on a different regimen, dietetic and medicinal, improvement sets in. 
But these persons are often hard to convince. At first sight it does 
seem an odd way to increase the strength, viz., cutting down the food, 
and especially the animal food. But the alteration is soon felt. 
4 She stoops to conquer.' And this manoeuvre can be practiced with 
satisfactory results in hepatic inadequacy. No chain is stronger than 
its weakest link. The appetite may be fair, the stomach capable ; 
but the liver is weak. The nutrition is defective usually when the 
liver is incapable, and the appetite fails. That is nature's way of 
attaining a new balance by ' leveling down.' But an appetite is held 
to be a man's inalienable right ; and so he tries artificial means to 
create one. He defeats his own ends. He thwarts and traverses 
nature's provisions, and so the plan fails. When the liver is inca- 
pable it is well to reduce the demands upon it to its capacities. 

" Now about the drink. A naturally feeble liver cannot get on 
with malt liquors. Whether it is cholaemia or lithsemia, malt liquor 
is pernicious ; especially with persons of the 4 Arab ' type, i. e., highly 
developed nervous system and small viscera. Malt liquors prepared 
by the English system of brewing are specially injurious to an inca- 
pable or sensitive liver. The beers brewed upon the German or lager 
system are less objectionable ; and many ' liverish ' persons can drink 
beer on the continent who cannot touch it in England. Generous 
wines, too, have an evil influence. The wine must be poor for most 
bilious persons. Often even wines must be foresworn and some weak 
spirits-and-water form the sole beverage or food adjunct." 



CONGESTION OF THE LIVER. 

Active Hypercemia. — This occurs physiologically after each meal ; 
but if a person eats too much, and of high-seasoned and stimulating 
food, taking with it a large quantity of wine or spirits, the conges- 



506 THE PRACTICE 'OF MEDICINE. 

tion becomes pathological. This hyperaemia, if frequently recurring, 
leads to functional disorder. Gastro-intestinal inflammations have 
the same effect. Bouchard says dilatation of the stomach is always 
attended by hyperaemia of the liver, due to the passage into it of 
toxic substances, the result of imperfect digestion. Suppression of 
the menses or a hemorrhoidal flux may induce it. It is of frequent 
occurrence at the " change of life." 

Climatic influences have much to do with hepatic congestion. In 
certain zones, and in certain temperatures, as in the torrid zone and 
in a hot and moist climate, few persons escape. It occurs during 
malarial fevers. Malaria, even if it does not cause ague, often excites 
congestion as a primary state. The symptoms are a decided increase 
in the size of the liver ; pain in the hepatic region encircling the 
base of the thorax like a girdle, and causing a sensation as if the 
clothing was too tight, or as if the stomach was too full. Then there 
are pains which radiate into neighboring parts, particularly the shoul- 
der of the right side, or under the right scapula. Monnerat says 
these congestions are accompanied by fever with paroxysms coming 
on every afternoon between 4 and 5 o'clock. (I have frequently 
observed this in malarious districts. The routine practitioner thought- 
lessly gives quinine, which only increases the congestion and causes 
hepatitis. The only proper treatment is to remove the congestion by 
the use of aconite, gelsemium, or mercurius, and some alkaline water 
like Congress, Carlsbad, or the phosphate of sodium.) 

With congestion of the liver we find dyspnoea, without any car- 
diac trouble ; or, sometimes dyspnoea with intermitting pulse, simu- 
lating disease of the heart. If we find these symptoms we should 
always carefully examine the heart. If that is found intact, we can 
safely diagnose hepatic hyperaemia. 

Treatment. — In acute congestions from overeating, or the exces- 
sive use of wine, or from becoming overheated, all that is necessary 
is a low diet of milk and rice gruel, or some such farinaceous food for 
a few days. If it is the result of chronic gluttony, little can be done 
except to order an aloin pill at night, with a dose of Rubinat or 
Carlsbad in the morning to carry off the surplus food and empty 
the portal system. Unless such patients change their habits and 
eat rationally, they sooner or later die of Bright's disease or apo- 
plexy. 



DISEASES OF THE DIGESTIVE SYSTEM. 507 

Simple congestion is relieved by such medicines as mercurius 
dulcis or vivus, podophyllin, or any of the hepatic remedies hereto- 
fore mentioned, which are indicated by the symptoms. I prefer mer- 
curius dulcis, of which I prescribe tablets of one-tenth of a grain 
before each meal and at night. Two days are sufficient to remove 
the hyperemia. 

If the patient is constipated and the mercurius does not move 
the bowels, give in the morning before breakfast a teaspoonful of 
powdered Carlsbad salts in a glass of hot water. When there is a 
remittent fever with the congestion, gelsemium, lycopodium, bryonia, 
chelidonium, sanguinaria, and carduus will be found useful. When 
the kidneys are obstructed and not able to carry off the effete mat- 
ters that the liver has not been able to destroy or eliminate, euca- 
lyptus and boldo will be found excellent remedies in doses of five to 
ten drops of the tincture every four to six hours. In very plethoric 
subjects I have often seen notable benefit from veratrum viride. 

Passive Hypercemia presents nearly the same train of symptoms 
as the active, but the causes are usually not the same. Chronic 
passive congestion may result from gluttony and alcoholism, but the 
usual cause is venous stasis in the right heart. This occurs in all 
mitral diseases, inducing venous stasis in the efferent vessels or sub- 
lobular branches of the hepatic veins. 

Emphysema of the lungs and inter-thoracic tumors may have the 
same result as valvular diseases. Gastro-intestinal catarrh, dilata- 
tion of the stomach, and haematemesis may attend this form of con- 
gestion. 

The liver sometimes becomes enormous, extending six inches below 
the costal margin. Pulsation is sometimes felt in it. It is not the 
communicated throbbing of the heart that is felt, which is very dif- 
ficult from the heaving, diffuse impulse due to regurgitation into the 
hepatic veins, in which, when one hand is upon the ensiform carti- 
lage, and the other upon the right side at the margin of the ribs, 
the whole liver can be felt to dilate with each impulse. 

In these severe cases, it has been observed that haematemesis, 
hemorrhage from the bowels, or from piles, promptly relieves the 
congestion and lessens the size of the liver. This has led to the 
Anglo-Indian practice of aspirating the liver, " drawing off eighteen 
to twenty ounces." This operation has been frequently performed 



508 THE PRACTICE OF MEDICINE. 

by the surgeons of our Southern States. In our Northern States 
such severe congestion rarely occurs. In two cases under my observ- 
ation, in men who had lived several years in Louisiana, I relieved 
them by the use of agaricus and aurum muriaticum. They had pre- 
viously been drugged with calomel. 

Agaricus and aurum have been found of great value in hepatic 
enlargements from engorgement. 

In Dr. Burnett's very interesting little volume on " The Greater 
Diseases of the Liver," he gives many illustrative cases where 
enlargements with probable organic changes recovered under the use 
of the hepatic remedies I have mentioned. Nearly all medicines 
which increase the functional activity of the liver do so by increas- 
ing the circulation in the liver. In toxic doses, this increase reaches 
pathological congestion, primarily acute, secondarily passive. 

But when the passive hyperemia is due to cardiac changes our 
remedies should not be wholly directed to the liver, but to the heart. 
These cardio-hepatic congestions require digitalis, strophanthus, con- 
vallaria, cactus, strychnine and other cardiac restoratives. The great 
value of euonymin in such cases is due to its influence on the heart 
and liver ; podophyllin has some such action. 

One of the most enormous livers I ever saw, attended with ascites, 
jaundice, feeble heart, intermitting pulse, and bile intoxication, was 
relieved in a few days by mercurius dulcis, two grains every four 
hours, alternated with tablets of digitalis and strychnine 2x. 

Dujardin Beaumetz ("Diseases of the Liver"), in summing up 
the treatment of chronic hyperemia, says : " But of all the curative 
means employed, the most effective is the thermal treatment. Here 
we witness the triumph of Yichy and Carlsbad." Our school in this 
country have reprehensibly neglected the great aid we can gain from 
the methodical use of similar waters which are found here. Noth- 
ing can be accomplished in these passive hyperemias, unless we 
reduce the diet of the patient to rational limits. All alcohol, sugar, 
new bread, high-seasoned soups and meats, except fish and lamb, 
must be given up. If this does not suffice, and the patient has not 
a dilated stomach, put him on a diet of Vichy and milk with zwie- 
bach ; a glass of half milk and half Vichy, with a slice or two of 
zwiebach, every three hours. This will soon reduce the size of the 
liver, and lessen the engorgement. This diet will not distress the 



DISEASES OF THE DIGESTIVE SYSTEM. 509 

patient as much as he thinks, but he cannot engage in hard physical 
labor ; he should, however, exercise in the open air. Euonymin 2x 
and nux 2x are admirable remedies in such conditions. 

Dr. Burnett, in his little treatise, shows such an intuitive appre- 
ciation and knowledge of the curative powers of our indigenous 
remedies that I cannot forbear quoting some of his cures of the con- 
dition he terms enlargement of the liver. This condition was prob- 
ably intense engorgement, for we cannot believe any remedy will 
remove interstitial growth of that organ. Burnett quotes Rade- 
macher's theory of the action of chelidonium, — that it affects the 
inner liver. As he gives the symptoms of this derangement of the 
inner liver, we know that the hepatic cells were in a condition of 
functional derangement. Chelidonium has no rival in this respect. 
It also deranges the venous circulation in the liver, causing hyper- 
emia with enlargement. 

Burnett reports a case of enlarged liver with jaundice in a woman 
of seventy, presenting all the typical symptoms of hyperemia, which 
he cured in ten days with " small material doses " of chelidonium. 
Another case, a young officer from India, with enlarged and engorged 
liver and right lung, was cured with chelidonium. Burnett states 
that a differential diagnosis between chelidonium and carduus can 
be found in the fact that the former is indicated where the enlarge- 
ment is " in the perpendicular line," while the latter cures enlarge- 
ments " in the transverse measurement." This might be considered 
conjectural did he not give illustrative cases. He does give several 
wherein he uses material doses of each drug, five to ten drops sev- 
eral times a day. He gives a curious indication for carduus, namely : 
the sternal brownish patch of skin, the same that the laity call a 
" liver spot." Burnett thinks that this spot indicates disease of the 
left lobe of the liver. He reports four cases of hyperemia with jaun- 
dice and dyspepsia, and presenting the sternal patch, cured promptly 
by carduus. 

The late Dr. William Morgan, of England, who wrote a small 
treatise on Diseases of the Liver, and their homeopathic treatment, 
recommends ammonium muriaticum, and quotes Dr. Budd, who 
records in his great work, now out of print, cures of enlargement 
of the liver and spleen from the use of this medicine in five to ten 
grain doses three times a day. The enlargements had lasted nine 



510 THE PRACTICE OF MEDICINE. 

months, and were attended by emaciation, pallor, and irritative fever. 

Surgeon-General W. Stewart, in a communication on this subject 
to the " Lancet," refers to a former communication of his in which 
he showed that in hepatic congestion, a local depletion of the portal 
capillaries is effected by each succeeding dose of chloride of ammo- 
nium, and that this depletion, unlike that obtained by other meas- 
ures, was not attended by depression. After stating that, with the 
exception of Professor Aitken, the other men in England who had 
used the treatment had not given the necessary attention to diet and 
management, without which successful results could not be attained, 
he proceeds to detail the characteristic symptoms produced by the 
drug in hyperemia of the liver. " These symptoms occur shortly 
after the medicine is taken, in from five minutes to half an hour. 
Sometimes a shock is felt, as if ' something gave way ' in the side ; 
at other times a succession of shocks is experienced in the hepatic 
region, accompanied or not by a prickling sensation, ('pins and 
needles '), or as if cold water were trickling down the side ; or, the 
action is described as that of ' pulling ' one hypochondrium to the 
other, or from the margin of the right costal arch upwards, and 
backwards, as if through the liver ; or a ' clawing,' ' working,' or 
y gnawing ' sensation is spoken of as felt by the patient. With the 
local actions excited in the liver and related parts, motor impulses 
are similarly communicated to the muscles of the intestinal canal, 
increasing peristalsis. 

" Looseness of the bowels does not, however, contra-indicate the 
chloride of ammonium. The only thing which contra-indicates the 
immediate use of the drug in acute cases is the existence of combined 
hot and dry states of the skin, with pyrexia. Under such circum- 
stances, its use should be preceded by a few small and frequently 
repeated doses of solution of acetate of ammonium, till the skin is 
rendered moist. Fomentations or hot bran-bags applied to the seat 
of the pain in the side will be of use in aiding determination to the 
skin generally." The author gives the drug in doses of twenty 
grains three times daily. (Our lx trituration of ammonium muri- 
aticum will act as well — even in cases where Dr. Stewart says it is 
contra-indicated.) 



DISEASES OF THE DIGESTIVE SYSTEM. 511 

HEPATIC CONGESTION IN CHILDREN. 

This article would be imperfect did it not include congestion of 
the liver in children. It is quite common in children who are 
brought up artificially and are allowed to eat all kinds of sweet and 
highly seasoned foods. It is frequent in malarial regions, and then 
is coincident with enlargement of the spleen. 

There is no mistaking the symptoms unless the case is quite recent, 
and there is yet no enlargement of the liver. As an illustration — a 
child of three to five years is brought to us. He is pale, a sallowy 
paleness with a lemon tint to the skin. The face seems bloated — 
especially the lips, sometimes only the upper. The tongue is flabby, 
broad, with indentations of the teeth on the edges. The eyes are 
dull, the conjunctivae muddy. An examination shows the abdomen 
enlarged, sometimes greatly so, and on percussion the lower border 
of the liver reaches to the level of the umbilicus. It is hard and 
somewhat sensitive. The urine is yellow and scanty. The stools 
may be thin or hard, but are always gray, chalky, or like mortar. 
The stools of enlarged liver must be distinguished from those of indi- 
gestion in children fed exclusively on milk or farinaceous food. The 
stools in such cases are light-colored, offensive, putty-like, or thin, 
but they consist of undigested food and the liver is not enlarged. 
The general appearance of the child is similar to one with hepatic 
disorders. The urine, however, is red rather than yellow, or more 
often white or milky, consisting largely of phosphates. In such cases 
the children need a change of food, from milk and starch to mutton 
broth, albumen of eggs, with as little farinaceous matter as possible, 
and that had better be in the form of baked flour, zwiebach, etc., with 
such remedies as Pulsatilla, calcarea, euonymin, podophyllin, together 
with pepsin and pancreatin, or papoid. 

But if the liver is hyperaemic and enlarged, the hepatic remedies 
alone are sufficient to relieve all the symptoms. It should be remem- 
bered that the liver of a child is proportionally larger than that of 
an adult and that it requires relatively more medicine to act upon it. 
A non-recognition of this fact brought me some of the bitterest expe- 
riences in my early practice. I recall two children, who came under 
my care with the typical symptoms mentioned above. Following the 



512 THE PRACTICE OF MEDICINE. 

recommendation of Hartman and Laurie I prescribed mercurius sol- 
ubilis 6x, cinchona 6x, calcarea 6x, and several other medicines from 
the 3d to 6th. The children did not improve during the week or 
two they were under my care, notwithstanding the careful diet I 
ordered. The parents naturally became dissatisfied and consulted 
an old physician of the regular school. In four or five days the lit- 
tle patient had changed wonderfully for the better, and I lost much 
prestige. I ascertained that they were given mercurius dulcis (cal- 
omel), one grain every three hours, until the stools became colored 
with bile. After that they needed no medicine for the liver decreased 
in size, the appetite returned, and a rapid recovery followed. I was 
not above learning from my colleague, and since that time I have 
never been caught in a similar blunder. Mercurius dulcis or vivus 
lx is the chief remedy, but I have cured several cases with euonymin 
lx when there was diarrhoea ; podophyllin 2x when there was 
also distension of the colon ; chelidonium when there was a cough 
and pain under the right scapula and other remedies failed. The 
conditions above described are often mistaken for worms, and nearly 
all the cases brought me had been dosed with vermifuges. Worms 
may be found in the stools, but they are not the cause — rather a 
consequence of the state of the intestinal secretions. I believe, how- 
ever, there have been a few cases recorded where jaundice and 
enlarged liver in children has been caused by the presence of lum- 
brici in the gall-duct. 



JAUNDICE WITHOUT OBSTRUCTION. 

This condition will occur when the bile is poured out into the 
bowels, even when it is secreted too abundantly. According to Mur- 
chison this is due : 

(1) To the presence in the blood of poisons that oppose the nor- 
mal metamorphoses of bile. 

(2) To enfeeblement, or disorders of the innervation controlling 
these metamorphoses. 

(3) To insufficient oxygenation of the blood, which has the same 
result. 

(4) To hypersecretion of bile, more being absorbed than can be 
transformed in the normal state. 



DISEASES OF THE DIGESTIVE SYSTEM. 513 

(5) To abnormal retention of bile in the bile-ducts and intestines 
by reason of habitual or prolonged constipation. 

There are several theories as to the manner in which icterus with- 
out obstruction is brought about. Those who have ascribed icterus 
without obstruction to alterations in the blood, support one of two 
theories : the one advocated by Frerichs, the other by Kuhne. 
According to the teachings of Frerichs, the bile which flows into the 
intestines passes in the normal state back into the blood, where the 
biliary acids are transformed into the coloring matter of the bile ; 
then this coloring matter is burned and destroyed as fast as produced. 
But let any circumstances oppose this oxidation, and the bilirubin, 
being no longer burned, passes into the blood and the different hu- 
mors of the economy. According to this theory, the failure of oxida- 
tion is the cause of this hematogenous icterus, which it will not do 
to confound with hsemaphaeic icterus. Murchison has made of this 
a special group under the name of icterus by insufficient oxygenation 
of the blood. According to Kuhne, whose explanation starts from 
similar data, the bile which passes into the intestines under normal 
conditions is reabsorbed into the blood, where the biliary acids (as 
seems demonstrated by experimentation) destroy the globules and 
set at liberty the haemoglobin which is transformed into bilirubin. 
When the transformation is too active, naturally the bilirubin would 
accumulate in the blood and produce jaundice. Other physiologists 
regard this jaundice as simply and solely due to reabsorption of bile 
from the surface of the intestine. Lussana and Schiff ascribe a 
great importance to this u entero-hepatic circulation," which they say 
goes on between the intestine and the liver. The bile poured into 
the intestine is reabsorbed by the portal circulation, and returns to 
the liver, to be anew excreted into the intestine. It is easy to under- 
stand that when the biliary secretion is too abundant, a certain quan- 
tity of bile and coloring matter may pass into the blood and produce 
jaundice. Yulpian has, in fact, shown, in contradiction to the experi- 
ments of Feltz and Hitter, that when bile is injected into the veins 
of animals, jaundice is produced. Lastly, other physiologists have 
maintained that it is in the liver itself that we are to look for the 
cause of jaundice without obstruction, and in certain pathological cir- 
cumstances the bile which is secreted in the hepatic cells may pass, 
not into the radicles of the bile-ducts which surround them, but 

33 



514 THE PRACTICE OF MEDICINE. 

directly into the network of blood-vessels with which the liver is so 
richly endowed. 

Dujardin-Beaumetz, in commenting on these theories, says : "All 
these theories may find their application in individual cases belong- 
ing to the large group of icterus without obstruction. Which of 
these theories shall we adopt ? Is there any one which responds 
better than the others to the different facts which clinical experience 
furnishes ? No, all the theories which I have enumerated may find 
their application in individual cases belonging to the large group of 
icterus without obstruction. Jaundice with polycholia, in which con- 
gestion of the liver entails a more abundant secretion of bile and 
the production of icterus, we would explain by the resorption of bile 
from the surface of the intestine. In other circumstances, the icterus 
results manifestly from an alteration of the blood. Thus it is that 
certain animal poisons and certain miasms may be the cause of this 
affection. In such cases we get most light from the theories of 
Frerichs and of Kuhne, which find the cause of the jaundice in pri- 
mary alterations of the blood. As for the cases of icterus called 
4 nervous icterus,' which are occasioned by strong emotions, anger, 
fright, etc., and which we cannot explain either by spasm or paraly- 
sis of the bile-ducts, we are obliged to hypothecate disturbances of 
the cerebro-spinal axis and particularly of the bulbus, which deter- 
mine direct modifications in the circulation of the bile in the hepatic 
cells ; it would seem that the bile, instead of passing from the hepatic 
cell into the bile-ducts, finds its way into the capillary network. 
According to Frerichs, in icterus from mental emotions the troubles 
of innervation may conduce in two ways to the accumulation of bile 
in the blood : 

(1) By modifications in the hepatic circulation, due to the influ- 
ence which the nerves exercise on the calibre of the branches of the 
venae porta?. 

(2) By perturbations in the action of the heart or in the respi- 
ratory movements, as well as in the renal secretion. 

What are the therapeutic indications for the treatment of jaun- 
dice without obstruction, based on the data which I have just given ? 
In combating these kinds of jaundice, we should attack the primary 
cause which has occasioned the jaundice : oppose the alteration of 
the blood in cases of hematogenous icterus ; re-establish the functions 






DISEASES OF THE DIGESTIVE SYSTEM. 515 

of the liver in those which are due to excess of the biliary secretion ; 
and calm nervous perturbations in jaundice resulting from strong 
emotion ; such are the principal indications to fulfil in the treatment 
of jaundice without obstruction." 

There is still another variety of jaundice called " grave or per- 
nicious icterus." It might properly be called " cholaemia," corres- 
ponding to " uraemia." It is thus described by various writers : 

Grave icterus (acute, pernicious, typhoid, hemorrhagic, essen- 
tial, fatal icterus), which Monneret defines : " A bilious, icteric, 
remittent, hemorrhagic, and adynamic fever, whose almost constant 
termination is death," may be observed at all ages, but it presents 
its maximum of frequency between the ages of eighteen and thirty 
years. Pregnancy seems to be a predisposing cause (Charcot, Frer- 
ichs, Laborde, and others). Out of thirty-one cases, Frerichs found 
nine in the male and twenty-two in the female ; one-half of the lat- 
ter were connected with pregnancy. Lebert's statistics give forty 
men and only twenty women. Syphilis is said to be a predisposing 
cause, also excessive labor, malaria, drunkenness, etc. The disease 
has prevailed epidemically within narrow areas (barracks, prisons, 
ships). Grave icterus may be grave from the onset ; oftener per- 
nicious symptoms set in during the course of an attack of jaundice. 
In the great majority of cases softening or destruction of the liver 
has been found in connection with it (acute yellow atrophy). The 
onset is often insidious. If sometimes the disease begins suddenly 
by a chill, headache, vomiting, generally the first symptom is a sim- 
ple digestive disorder. The patient complains of fatigue, is in bad 
trim, without appetite, with a little headache, fulness at the epigas- 
trium or over the liver. These symptoms go on increasing, the patient 
gets weaker and weaker. The jaundice first appears limited to the 
conjunctivae, and extends to the rest of the body. Coincidently 
there are often hemorrhages of variable magnitude, from the bloody 
oozing of the gums, sanguinolent expectoration, cutaneous extrava- 
sations, to copious bleeding from the stomach, nose and intestines. 
The fever, which was nil or intermittent at first, becomes ordinarily 
remittent about the eighth day, with nocturnal exacerbation and agi- 
tation. The debility augments, and yet there is sometimes on the 
part of the patient a gaiety and an indifference which contrasts sin- 
gularly with the gravity of the general condition. The intelligence 



516 THE PRACTICE OF MEDICINE. 

remains intact ; it is not till the last stages of the disease that the 
patient is delirious or convulsed in the trunk and limbs ; a persistent 
hiccough sometimes complicates the suffering of the patient. The 
heart sometimes presents a murmur, due, according to Potain, to a 
temporary tricuspid insufficiency. The urine shows nothing char- 
acteristic at the onset, but soon becomes of high color and may be 
bloody, either from passage of the coloring matter of the blood or 
blood itself into the renal secretion. The urea seems to augment at 
first, then diminishes, and may fall as low as 50 c. c. in the twenty- 
four hours. Leucin, tyrosin, xanthin, and hypoxanthin, sometimes 
albumin, are found in the urine. The microscope reveals casts and 
bloody globules. In cases that terminate favorably, amelioration 
is ushered in by a copious diuresis. The progress of grave icterus 
is rapid ; death sometimes supervenes the fifth or sixth day, gener- 
ally from the seventh to the twelfth day. The patient succumbs in 
a state of somnolence, coma, algidity, or in convulsions. Although 
the termination is generally fatal, yet quite a number of cases of 
recovery have been reported." 

From the above description you see that occasionally in jaundice 
symptoms of the greatest gravity appear. Hemorrhages from the 
mucous membranes supervene ; cerebral disorders manifest them- 
selves ; the patient falls into profound adynamia and succumbs more 
or less rapidly. 

The uncertainty as to the cause of this pernicious form makes the 
treatment very uncertain. Old-school authorities fall back on the 
use of cinchona and quinine, simply as tonics against the adynamic 
condition. In our school, we are obliged to treat the patient accord- 
ing to the totality of his symptoms. 

Picric acid corresponds to all the symptoms, but unfortunately 
the jaundiced color of the skin caused by that drug has not yet been 
proved to be due to the presence of bile or any of its elements in 
the blood. But after all, picric acid may be a good remedy for it. 
The serpent-poisons may prove curative, for their general effects are 
quite similar. Grave cases of jaundice have been cured by lachesis 
and crotal ; plumbum, copper, and phosphorus may be found to be of 
value. 

The treatment of icterus from emotions or other neurotic influ- 
ences will have to be treated according to the law of similia. Col- 



DISEASES OF THE DIGESTIVE SYSTEM. 517 

ocynth and chamomilla have cured such cases, and it is said that nux 
vomica and ignatia have been useful. The jaundice occurring in 
the infectious and contagious fevers is a part of the general condi- 
tion and must be taken into consideration when selecting the remedy. 

Another cause of jaundice without obstruction, mentioned by 
Legg, is one I have several times alluded to in my " Lectures on 
Diseases of the Heart," viz : decreased pressure of blood in the blood- 
vessels of the liver. If the pressure of the blood upon the sides 
of the vessels in the liver be decreased, the bile will pass in the direc- 
tion of least resistance, that is, into the circulation. Heidenhain has 
given experimental evidence of the truth of this hypothesis. He 
found that on decreasing the pressure of the blood in the vessels of 
the liver, the bile already formed began to pass into the circulation. 

This lowering of the blood-pressure in the liver may be caused : 
by (a) plugging of the portal vein in cases of pigment liver, bleed- 
ing from the roots of that vein, yellow fever ; by (b) too high arte- 
rial tension from arterial sclerosis ; and by (c) a weak heart, with or 
without stenosis or regurgitation. 

I have already mentioned how the absorption of bile into the blood 
causes a slow pulse and weak heart, and even structural changes. 
Now suppose we have a patient with weak heart from any cause ; 
the blood-pressure in the liver is less than normal. Those who have 
treated many cases of heart disease are aware that attacks of jaun- 
dice are very frequent, when the heart's action is quite low ; and 
they must have observed, as I often have, how quickly the jaundice 
will disappear under the influence of medicines that impart strength 
to the heart. Digitalis, sanguinaria, strophanthus, cactus, strychnine, 
and muriate of hydrastin (the white alkaloid) are the most potent 
remedies for this state. In the country, in domestic practice, the 
people have great confidence in wild cherry bark (prunus vir.) in 
jaundice. I have observed cures from its use, but the patients were 
delicate persons with poor circulation, or suffering from pulmonary 
or cardiac diseases. It was usually taken in decoction, or a satur- 
ated tincture made with whisky. Prunus vir. is a cardiac tonic of 
no mean power. The fact that the slow or intermittent pulse of 
jaundice is worse when sitting or lying, and becomes more regular 
and stronger when walking, suggests that, if there is no structural 
weakness or obstruction in the heart, we should advise exercise, 



518 THE PRACTICE OF MEDICINE. 

fresh exhilarating air, and a little alcoholic stimulant. If arterial 
tension is the cause of the deficiency of blood-pressure in the vessels 
of the liver, it may be due to vaso-motor contraction, or sclerosis. 
If the former, the remedies are glonoine, veratrum viride, nitrite of 
sodium, and aconite. If the latter, iodide of sodium or iodide of 
barium should be alternated with glonoine or one of its analogues. 

If there is anseinia some preparation of iron may be given — the 
lx of iron by hydrogen ; the syrup of succinate of iron, which is 
believed to be the best in all cases of diseases of the liver ; or some 
mineral water containing iron combined with alkalies. 

The hemorrhages occuring in jaundice are often profuse and pros- 
trating. The best remedy I ever used in such cases is hamamelis ; 
not the dilution but twenty to thirty drops of the tincture every two 
or four hours. Next in value is dilute sulphuric acid, ten drops in 
a little water every hour. Carduus is often equal to either of the 
above, in doses of ten to fifteen drops every hour. It matters not 
where the bleeding may be — in nose, lungs, or bowels — these reme- 
dies are fully indicated. 

ICTERUS (Jaundice). 

All cases of jaundice may be referred to one of two classes : 

(1) Cases in which there is a mechanical impediment to the flow 
of bile into the duodenum, the bile in consequence being retained in 
the biliary passages, and absorbed thence into the blood. 

(2) Cases in which there is no impediment to the escape of bile 
from the liver into the bowel. 

Mechanical obstruction may be subdivided as follows : 

(a) Obstruction by foreign bodies within the bile-duct. 

(1) Gall-stones, and inspissated bile. 

(2) Hydatis, distoma. 

(3) Foreign bodies from the intestine. 

(b) Obstruction by inflammatory tumefaction of the duodenum, 
and lining membrane of the duct. 

(c) Obstruction from congenital deficiency of the duct ; stricture 
from peri-hepatitis ; ulcers in the duodenum and bile-ducts, and spas- 
modic stricture — if such a condition can exist. 

Murchison mentions many more causes, but they are so very rare 



DISEASES OF THE DIGESTIVE SYSTEM. 519 

that we need not consider them at all. Jaundice in pregnant women 
from pressure of the uterus ; and jaundice from enormous accumula- 
tion of faeces in the colon, and from large tumors of all the abdom- 
inal organs, are of more frequent occurrence. 

Cases of jaundice under class 2, in which there is no impediment 
in the bile-duct are due to — 

(a) Poisons of the specific fevers : yellow fever, remittent and 
intermittent fevers, relapsing fevers, typhus, scarlatina, and " infec- 
tious jaundice." 

(b) Pyaemia, snake poisons, phosphorus, mercury, copper, anti- 
mony, chloroform, ether, and all drugs which act as powerful hepatic 
stimulants, may cause jaundice as a secondary effect. Severe men- 
tal emotions, fright, anxiety, anger, constipation, congestions of the 
liver, etc. 

" When any obstruction exists to the flow of bile through the 
hepatic or common bile-duct, the way in which jaundice arises is suf- 
ficiently clear. The bile-ducts and the gall-bladder become distended 
with bile, which is absorbed into the blood by the lymphatics and 
the veins. This was satisfactorily proved at the end of the last cen- 
tury by the experiments of Dr. Saunders, which have been confirmed 
by many subsequent observers. If a ligature be applied to the 
hepatic duct of a dog, and the animal be killed after two hours, the 
lymphatics in the walls of the bile-ducts, which are very numerous, 
are seen to be distended with a yellow fluid ; the fluid in the tho- 
racic duct is also yellow, and so likewise are the intervening lym- 
phatic glands. In patients, also, who die of obstruction of the bile- 
duct the lymphatics of the liver are often found to contain bile. 
On the other hand, the serum of blood taken from the hepatic vein 
two hours after ligature of the common bile-duct is found to contain 
much more bile-pigment than that of blood taken from the jugular 
vein, which shows that, in obstruction of the gall-duct, bile is also 
directly absorbed by the veins. (Murchison.) 

The diagnosis of jaundice from obstruction of the bile-duct is 
simple : Examine the faecal discharge and the urine. If both con- 
tain bile, the case is one of obstruction. The examination with the 
naked eye by an experienced physician is generally sufficient. If 
there is any doubt, use the iodine test, which causes an emerald green 
tint when a few drops are added to a thin film of urine on a plate ; 



520 THE PRACTICE OF MEDICINE. 

or you can filter a little of the urine, and from a pipette let fall a 
few drops of nitric acid on a small quantity in a test-tube ; you will 
observe a beautiful play of colors, yellow, green, blue, violet, and red. 

The two most common causes of jaundice you will have to deal 
with are gall-stones, and catarrhal inflammation of the duodenum 
and gall-duct. 

The treatment of gall-stones will be found in another chapter. 
Catarrh of the gall-duct is generally an extension of catarrhal gas- 
tritis. The duct swells inside, the membrane exudes a tenacious 
mucus which plugs up the already narrowed calibre of the canal. 
Unlike jaundice from gall-stones, which comes on suddenly after an 
attack of bilious colic, catarrhal jaundice is gradual, and preceded 
by catarrh of the stomach, which may extend throughout the whole 
digestive tract. 

The chief remedies are gelsemium, hydrastis, myrica, podophyl- 
lin, nux vomica, salicylate of sodium, iodide of arsenic, or any drug 
causing gastric catarrh. Gelsemium seems to be capable of arrest- 
ing the catarrhal inflammation at its onset. It is not of much value 
when the catarrh has become fixed. Hydrastis is invaluable when the 
gastric and duodenal mucous membrane exudes large quantities of 
whitish-yellow mucus, with much vomiting. Our provings do not 
show any jaundice from hydrastis because they were not carried far 
enough. Myrica, which was proved under my supervision, caused a 
typical catarrhal gastritis with vomiting of thick, tenacious mucus, 
jaundice from obstruction, etc. Dr. Burnett reports several cases of 
extreme jaundice cured by both. Podophyllin causes a true catarrhal 
duodenitis followed by jaundice, and the cases reported from its use 
are innumerable. Nux vomica is the specific for the gastritis of 
gluttons and spirit-drinkers. The lx of the tincture, and 3x of the 
myrica, podophyllin, or hydrastin, should be used. Nux lx to 3x, 
salicylate of sodium lx, is an excellent adjuvant — ten grains in 
a glass of Vichy or Carlsbad water. They thin the bile, and 
increase the quantity, and thus aid in expelling the plug in the duct. 
If accumulation of faeces is found, distending the colon until it pushes 
up the gall-bladder, give castor oil and olive oil, equal parts, a table- 
spoonful every hour or so until the colon is empty. This may have 
to be aided by massage of the colon, and glycerine enemata. 

I have seen many cases of jaundice in the last month of preg- 



DISEASES OF THE DIGESTIVE SYSTEM. 521 

nancy, but never found any medicine to remove it. We must wait 
for the uterus to be emptied by labor. Spasm of the duct is denied 
by many, but I believe it may exist. It can be caused by fright, 
anger, or other neurotic irritation, and we know it exists during the 
passage of gall-stones. It is in such cases that belladonna, chloro- 
form, and nitrite of amyl have given relief. 

When inspissated bile causes obstruction it must be preceded and 
attended by an abnormal secretion of bile, thicker in consistence 
than the normal fluid. Such bile is dark in color and contains more 
solid matters. The treatment of this obstruction is by giving those 
drugs which thin the bile and lessen its solids. The waters of Vichy, 
Carlsbad, Congress, and French Lick do this. So do the acid fruits 
(without sugar), for in the stomach they form alkaline salts. The 
medicines indicated are iridin, chelidonium, chionanthus, carduus, 
euonymin, nitro-muriatic acid, and salicylate of sodium. Flushing 
the colon with cool alkaline water is useful, as it excites reflexly the 
bile-ducts to expulsive action. 

Diet. — Contrary to popular prejudice the best diet in obstructive 
jaundice is milk in some form, I prefer skimmed milk or butter- 
milk, taken with Vichy, Seltzer, or Apollinaris water, equal parts. 
Allow no farinaceous or nitrogenous foods, rather fresh vegetables 
and sour fruits if they do not disagree with the stomach. The milk 
should be given regularly, a glass every two hours during the day 
until the patient falls asleep, at night. Do not allow constipation to 
exist. If fruits and enemata do not clear the colon, give olive oil, 
which is a cholagogue, a tablespoonful every four hours ; and failing 
with that a pill of " aloin, belladonna, strychnine, and ipecac," or 
one-fifth of a grain of pure aloin — at night. 

Dr. Jean de Wee, of Brussels, in the " Revue Homoeopathic 
Beige," refers to the properties of dolichos pruiens in controlling 
the pruritus which accompanies many forms of jaundice. In two of 
his cases, one a case of tumor of the liver, and one of recurrent jaun- 
dice from congestion, due to lithiasis, it did signal service. In the 
former he gave the mother tincture, in the latter the 3x dilution. 
In a case of catarrhal jaundice without pruritus it completely failed 
to do any good, carduus marianus proving very effective after its 
failure. 

Such are the most common and useful therapeutic measures in 



522 THE PRACTICE OF MEDICINE. 

this affection ; by their use the catarrhal jaundice may disappear 
quite promptly, but in other cases it is more persistent and may last 
for months. It will be necessary then to have recourse to other 
means which fulfil the second indication mentioned, viz. : to combat 
the symptoms caused by the passage of bilirubin into the blood. 
This therapeutic indication is especially applicable to persistent and 
chronic icterus, which manifests itself constantly by such symptoms 
as these : — there is obstinate constipation, but this is not all, the 
intestinal acholia also prevents regular absorption from the surface 
of the intestine. Hence the phenomena which have been noticed in 
jaundice by obstruction ; retardation in the functions of nutrition, 
bleaching of the faecal matters, which often have a horribly foetid 
odor. Such are the symptoms produced by acholia. 

In treating jaundice I always give one or two grains of ox-gall 
with each meal. Bile excites the peristaltic movements and clears 
the bowel, neutralizes the acidity of substances peptonized by the 
stomach, and, to a certain extent, opposes the fermentation of mat- 
ters contained in the intestines, and perhaps favors the digestion of 
fatty substances. We must administer food in little quantity and 
such as demands but little work on the part of the intestine ; we 
must also take care that what the patient eats shall not give rise to 
too active a fermentation in the intestine ; and the most of these 
indications, it must be admitted, are met by an aliment whose utility 
Dujardin so highly extols, viz.: milk. 

You want especially to combat here the symptoms arising from 
intestinal putridity, which result from absence of bile in the intes- 
tine ; bile being, as I have said, an antiseptic agent of the first order. 
For my part, I am persuaded that in explaining the nervous symp- 
toms which ensue in prolonged cases of jaundice, we should make 
much account of the penetration into the economy of putrid sub- 
stances and of ptomaines absorbed from the surface of the intestine. 
For this purpose I know of no agent superior to salol, in doses of 
three grains every six hours. It has some cholagogue action on the 
liver, also. 

Many other means have been advised. Some have proposed wood 
charcoal, others iodoform, others, as Bouchard, naphthalin or naph- 
thol ; Dujardin-Beaumetz recommends to employ sulphide of carbon 
water ; his formula is as follows : 



DISEASES OF THE DIGESTIVE SYSTEM. 523 

J^ Pure sulphide of carbon 25 grams. 

Water 500 grams. 

Essence of peppermint 30 drops. 

M. — Place in a flask capable of holding 700 cubic centimetres. 
Shake the mixture and allow it to settle. Decant off the clear solu- 
tion when needed. Renew the water as fast as it is poured off from 
the flask. You may give every day five or six teaspoonfuls of this 
bisulphide of carbon water, taking care to dilute each dose in half a 
tumbler of milk. In employing this simple remedy, he says you will 
see the foetidity of the stools rapidly disappear in the most intense 
cases of jaundice by retention. 

Bilirubin produces very painful cutaneous itching. I have known 
patients in whom this symptom became a veritable torture, and you 
must expect to witness this pruritus at advanced periods of icterus. 
What succeeds best in these cases is massage and vapor baths, and 
salicylate of sodium, which temporarily allay this aunoying pruritus. 
Lastly, bilirubin, in being absorbed into the blood, determines phe- 
nomena very similar to those caused by digitalis, i. e., it slows the 
pulse and circulation. Icterus even modifies the state of the heart 
muscle, and gives rise to a cardiac murmur. The study of the alter- 
ations of the heart produced under the influence of icterus is of quite 
recent date. These alterations manifest themselves by a bruit de 
souffle, the origin of which is not yet well known. This peculiar mitral 
murmur is accompanied by a presystolic bruit de galop. According 
to Fabre, there are three kinds of cardiac troubles in icterus ; troubles 
in the innervation of the heart, troubles in the nutrition of the left 
ventricle, and dilatation of the right ventricle. Moreover, it alters 
the blood crasis and gives rise to hemorrhages, of which Monneret 
has treated at length. It produces also in the mental functions a 
very peculiar modification to which alienists have called attention, 
"which manifests itself principally by hypochondriasis and profound 
gloom. 

I recall an obstinate case of catarrhal jaundice which gave me 
abundant proof that the heart may be poisoned by bile until struc- 
tural changes occur. The patient, a stout man of fifty, had never 
Iiad any heart trouble. I had examined him a short time before his 
jaundice and found the heart normal. An ordinary attack of influ- 
enza extending to the stomach resulted in duodenitis, with result- 



524 THE PRACTICE OF MEDICINE. 

ing jaundice. There was no appearance of bilious colic, the icteric 
hue of the skin coming on gradually, the skin assuming the hue of 
greenish-bronze at the end of three weeks. His mind was clouded 
and he was morose and gloomy. He took nux, cinchona, podophyl- 
lum and several other medicines, but without benefit. I observed 
that his pulse became slower and weaker day after day, and finally 
intermittent and irregular. On examination I found the abnormal 
sounds mentioned by Fabre. Leaving off all other medicines, I pre- 
scribed five drops of tincture digitalis every four hours. Improve- 
ment in the condition of the heart commenced at once; the bile 
appeared in the stools, and disappeared from the urine. The digi- 
talis, with nux vomica one-hundredth, five drops, was continued for 
several weeks, giving them only every other day, when I found the 
heart sound and rythm of the pulse normal. 

Eespiration has an important office in the combustion of the col- 
oring matter of the bile, which belongs to the group of carbon com- 
pounds, and Frerichs has rightly insisted on the utility of compelling 
the patient to live out-of-doors, take long walks, horseback rides, and 
indulge in gymnastic exercises. The kidneys play an important part 
in the elimination of bilirubin, and we find constantly in the urine 
of jaundiced patients a considerable quantity of this coloring prin- 
ciple. You must, then, promote the elimination of this substance. 
In grave icterus, if, for any reason, this emunctory becomes obstructed, 
accidents of high gravity supervene. Therefore I am fully of the 
opinion of Dujardin respecting the functions of the kidneys in jaun- 
dice, and ascribe to that organ an important role in the production 
of malign icterus. You ought, then, in chronic icterus, to administer 
the benzoates, benzoic acid, and especially milk, that admirable 
medicament, which, fulfilling special indications pertaining to diges- 
tion, also assists the elimination of bilirubin by the urine. Support 
also the forces of the patient ; do what you can to prevent hemor- 
rhages ; oppose the evils resulting from'retardation of the circulation, 
by subjecting your patient to a tonic treatment ; prescribe journey- 
ing and change of scene — you will thus divert your patient's mind 
from constant brooding over his disease, and antagonize the gloom 
and depression of spirits so common to icteric patients. Where 
the obstruction of the duct cannot be removed by medicine, two 
therapeutic means have been proposed : dilatation of the biliary pas- 



DISEASES OF THE DIGESTIVE SYSTEM. 525 

sages and gall-bladder ; aspiration or paracentesis of the gall-bladder 
and electrization according to the method of Gerhardt of Wurz- 
burg. As for the electrization of the gall-bladder in catarrhal 
jaundice, Gerhardt's method is of the simplest kind. He employs 
a strong faradic current. One pole is applied as accurately as pos- 
sible with some pressure (the place being determined by palpi- 
tation and percussion) over the region of the gall-bladder. The 
other pole is placed on the region of the back opposite, and now and 
then both poles are moved to and fro. Gerhardt claims remarkable 
results (even the overcoming of mucus obstruction and reduction 
of the gall-bladder) from this faradic treatment. (Gerhardt, in 
Berlin « Klin. Woch.," 1873, No. 47.) 

Dr. Legg, whose immense work on "The Bile, Jaundice, and 
Bilious Diseases " is a monument of erudition, mentions one cause 
of jaundice which should not be overlooked, namely, partial obstruc- 
tion of the ducts. 

The experiments of Heidenhain show that the pressure under 
which bile is secreted is extremely small. A very little obstruction 
to the passage of bile into the duodenum is needed to cause the bile 
to flow back into the blood. Nor is it necessary that the obstruction 
should be complete, but merely that the bore of the duct should be 
narrowed enough to cause the bile to pass with some trouble into the 
bowel. It would almost seem that the bile passes as readily into the 
circulation as into the duodenum ; thus jaundice may easily be caused 
by a hypersemic or catarrhal swelling of the parts of the common 
duct which passes through the walls of the duodenum, and yet after 
death all trace of swelling will have disappeared, and the duct will 
be fully patent. The only proof of the existence of an obstruction 
is the finding of the part of the duct below the obstruction uncol- 
ored with bile. We are sometimes surprised to find some bile 
in the stools, while the urine and skin shows its presence. The 
above explains the matter. A small stone may partially obstruct 
the duct, leaving just space enough for a little bile to escape. Straw- 
colored or lemon-hued stools would indicate that the obstruction is 
partial. It is probable that phosphorus may prove a remedy for 
catarrhal jaundice, for Wyss and Ebstein found in the livers of 
dogs and men poisoned by phosphorus that the finer ducts within 
the liver were plugged with a colorless mucus, a plain cause of the 



526 THE PRACTICE OF MEDICINE. 

jaundice. It may be that the suppression of the flow of bile caused 
by iodide of potassium, as observed by Rutherford, may have been 
due to the same cause. Both drugs may therefore be indicated in 
minute doses in catarrhal jaundice. 



GALL-STONES. 

Biliary calculus, says Dujardin, is a frequent affection, giv- 
ing rise to symptoms known under the name of hepatic colic. Before 
we enter upon the symptoms and treatment, let me refresh your 
minds concerning the anatomy of the gall-ducts. 

The hepatic duct takes its origin in the liver by that net-work of 
biliary canaliculi which surrounds the hepatic cells. After a short 
transit this duct meets the cystic duct from the gall-bladder, and 
both unite into one duct, the ductus choledochus, and empty into the 
duodenum by the ampulla of Yater. The mucous membrane of 
these ducts presents little valves or folds especially in the neighbor- 
hood of the cystic duct. The question whether these ducts pos- 
sessed muscular coats, although denied by Kcelliker, Virchow, and 
others, has been decided in the affirmative by the experiments of 
Renant and Grancher working under Dujardin-Beaumetz. The 
results of their labor were decisive ; both show that there undoubt- 
edly exist smooth muscular fibres in the bile-ducts, and that these 
muscular fibres are disseminated throughout the fasiculi of connec- 
tion and elastic tissue, constituting the fibrous coat of these ducts, 
and that inflammation taking place in the duct thickens this muscu- 
lar layer. So that it is now well settled that the excreting bile-ducts 
are fibre muscular tubes which are the seat of more or less energetic 
contractions. It has also been shown that under the influence of 
induction-currents the gall-bladder and bile-ducts all undergo man- 
ifest contractions. The calculi which pass through these ducts, caus- 
ing bilious colic, are variable in number and volume. In the vast 
majority of cases they are constituted of cholesterine, or bile pig- 
ment, forming stratified layers of different colors according as they 
are more or less colored by bilirubin. 

The number of calculi is very variable. Ordinarily from five 
to twenty are found in the gall-bladder. In some cases they are 
single ; in other cases considerable numbers are met with. In a 



DISEASES OF THE DIGESTIVE SYSTEM. 527 

woman, sixty-one years of age, Frerichs counted 1950. Morgagni 
has counted 3000, Hoffman 3606, and in the collection of Osto 
there is a gall-bladder containing 7802 calculi. All the calculi con- 
tained in the gall-bladder, whatever the number, are of the same 
chemical composition, color, and structure. Their size is variable, 
from a grain of millet seed to a hen's egg. Faneonneau-Dufresne 
has divided gall-stones into three classes : 

(1) Those of small size, from a grain of sand to a small pea. 

(2) Middle size, from a small pea up to a filbert. 

(3) Large size, from a filbert up to a hen's egg. 

The calculi may be olivary, pisiform, lenticular, polyhedric, cyl- 
indric, cubic, finger-shaped, have the form of dice, of coins, of pyra- 
mids, etc. They may be smooth, hollow, and striated, etc. But the 
ordinary typical form is the olive-shaped. The solitary calculi are 
roundish or ovoid. Multiple calculi ordinarily present facets, which 
appear to be due to the massing together of the calculi, and not to 
the friction of one upon another, for you do not often find, on exam- 
ining gall-stones, any interruption in the lamellae constituting them, 
which would be apt to take place if the facet was the result of fric- 
tion. 

Nevertheless, in 1851, Barth found in the gall-bladder of a woman 
of sixty-three years a dozen irregular calculi, with rough surfaces : 
he remarked that certain of these calculi had been broken and a 
little worn by friction. Other observers have recorded similar facts. 
Some have found in the gall-bladder, not stones properly so-called, 
but a thick, pasty, whitish mass composed almost entirely of chol- 
esterine (Besnier), or even a biliary sediment of the consistence of 
mud (Durand-Fardel). 

Ordinarily, however, the biliary concretions are quite consistent, 
although they are marked easily by the finger-nail : the hardest cal- 
culi are those of cholesterine. The structure of the calculi is vari- 
able, and has been well studied by numerous authorities, who have 
differently divided these biliary concretions. TTalter's classification 
is : (1) The striated calculi, transparent or opaque, which may be 
either smooth or anfractuous ; (2) the lamellated calculi, whose sub- 
stance is disposed in layers around a nucleus ; (3) calculi enveloped 
by a cortex. Hein's classification is: (1) ' ; Simple calculi"; (2) 
"composite calculi." Frerichs divides calculi into: (1) Simple 



528 THE PRACTICE OF MEDICINE. 

homogenous calculi, whose structure is uniform, whose fracture pre- 
sents an earthy, soapy, or crystalline surface, and which have neither 
nucleus nor cortex ; (2) composite calculi, presenting a central nucleus 
surrounded by a zone more or less thick, and covered by a cortex. 
The nucleus, brown or black, is composed of colepyrrhine and lime, 
cholate of lime, or of cholesterine. The nucleus, ordinarily single and 
central, is sometimes eccentric. There may even be in a calculus 
several nuclei. In a dry state these nuclei may undergo a sort of 
retraction, become split or even fragmented. The smaller the cal- 
culus, as a rule, the larger the nucleus. Cases have been men- 
tioned in which the nucleus was constituted by a foreign body, such 
as a lumbricus or blood-clot. The middle layer, immediately sur- 
rounding the nucleus, is generally striated, and constituted by crys- 
tals of cholesterine, pure or mingled with pigment. Concentric zones 
are also generally observed, indicating the growth of the calculus by 
successive strata. The cortex is generally more or less thick, some- 
times smooth and sometimes mammillated, but it is clearly distin- 
guished from the middle layer by its color, its stratified appearance, 
and its consistence. It is formed either by cholesterine, of bile pig- 
ment, or of lime. Biliary calculi are formed at the expense of the 
elements of the bile ; rarely they are composed of a single substance, 
they are ordinarily mixed. Cholesterine is generally the basis of these 
stones ; next in the order of frequency come bile pigment and lime 
salts. Charles Eobin divides calculi into calculi of cholesterine and 
calculus of coloring matter. Those of cholesterine pure are colorless 
or nearly white. Subjected on platinum foil to a lamp flame, they 
first melt, then burn like a fatty substance, giving off a sooty light. 
If the calculi is composed of pure cholesterine there remains no res- 
idue on the platinum foil. Insoluble in caustic potassium and 
sodium, they are very soluble in boiling alcohol and in ether. A 
drop of this ethereal solution under the microscope gives colorless 
rhomboidal plates by evaporation. Concentrated sulphuric acid 
colors these calculi yellow, and boiling nitric acid transforms them 
into cholesteric acid. 

The calculi of the coloring matter of the bile (biliverdine and 
cholepyrrhine) are brown, black or dark, deep green or greenish, 
according to the quantity of coloring matter. They do not melt 
when heated, they burn without flame, and leave a sooty residue. 



DISEASES OF THE DIGESTIVE SYSTEM. 529 

They are insoluble in ether and alkaline liquids. Treated by nitric 
acid, they pass successively through different shades of colors : green, 
blue, violet, red, and yellow. To ascertain the composition of the 
calculi, Luton, of Rheirns, has proposed a very simple method of 
analysis, which consists in subjecting a portion of the calculus to the 
action of solvents, hot alcohol, for instance, then allowing it to 
become cold ; crystalization takes place and the microscope enables 
one to recognize the principal constituent elements of the calculus : 
rhomboidal plates of cholesterine, needles and bacillary crystals of 
cholate of lime, etc. 

Under the name of biliary gravel, Fauconneau-Dufresne classes 
only such concretions as are under the size of the smallest lentil, and 
which present no appearance of structure. He gives three varieties : 
cholesteric gravel, pigmentary gravel, and melanic or carbonaceous 
gravel. 

I have said that the calculi are constituted by deposits of choles- 
terine ; what are the circumstances which lead to the precipitation 
of cholesterine ? We have to study the two following causes : either 
the cholesterine remains normal, or the other elements of the bile 
undergo modification and lead to precipitation of the latter. Let 
us take up the case where cholesterine is in excess, and here you 
must recall to mind what you know concerning its origin. 

Physiologists, as I have told you, are agreed in accepting Flint's 
conclusions, deduced from his careful experiments, and in consider- 
ing this substance as a product of disassimilation of the nervous sys- 
tem. This experimental datum seems to be confirmed, in a certain 
measure, by clinical experience, for it is principally in women with 
highly developed nervous systems that you observe biliary lithiasis ; 
and for my part, the more my attention has been directed to this 
explanation, the more firm is my conviction as to its truth. It is 
chiefly young women, nervous and impressible, who are the subjects 
of hepatic colic. It is probable that in these cases the too active 
exercise of the cerebro-spinal axis explains the excessive production 
of cholesterine and its precipitation in consequence of over-produc- 
tion, and I am convinced that this circumstance has not been suffi- 
ciently taken account of by the different authorities who have consid- 
ered this question. The second cause of the precipitation of choles- 
terine, i. e., the modification of its vehicle, the quantity of this sub- 

34 



530 THE PRACTICE OF MEDICINE. 

stance remaining the same, has been studied by Thenard, who has 
indicated, as a factor which may bring about this precipitation, the 
diminution of the salts of sodium. Moreover, Branson has shown 
that the appearance of lime in the bile may cause the precipitation 
of the coloring matter. Lastly, the bile, which in the normal state 
is alkaline, may become acid, and this is especially likely to take 
place under the influence of animal diet ; and acid bile favors the 
precipitation of cholesterine. Moreover, as we frequently find a 
nucleus of mucus in these calculi, we must assign an important role to 
the inflammations of the bile-ducts ; these inflammations cause a hyper- 
secretion of mucus which may give rise to a nucleus, around which 
the cholesterine deposits itself. Such are the physical and chemical 
causes which favor the production of calculi. It has not, in fact, 
been proved, either by experimental or chemical observations, that 
a diet exclusively of fatty food predisposes more than any other to 
biliary lithiasis. Another feature plays an important part in path- 
ogeny, namely, allowing too long an interval to elapse between meals. 
Physiology in fact teaches that during digestion the bile flows in 
great abundance into the duodenum, and that the gall-bladder nearly 
or quite empties itself at this time. We know also that one of the 
predominant causes of the precipitation of cholesterine in the bile is 
the prolonged sojourn of that liquid in the gall-bladder. When the 
meals are too far apart, or when, as is the practice of some persons, 
only one meal a day is eaten, the gall-bladder is placed in a favor- 
able condition for the precipitation of cholesterine. There is another 
factor which also aids the flow of bile, viz., the respiratory move- 
ments, which by the pressure which they effect upon the gall-bladder 
and the intestinal mass through the intermediation of the diaphragm 
tend to empty the gall-bladder. Hence the influence of want of 
exercise on the production of these calculi is apparent, and it is, in 
fact, sedentary persons whom we find to be the most subject to bil- 
iary lithiasis. Add that active respiratory movements favor the 
combustion of fatty matters, and you easily understand why we assign 
the first place to exercise in the hygiene of lithiasis. 

" The diatheses have a notable influence on the production of bil- 
iary lithiasis, and despite the opposition of Durand-Fardel to the doc- 
trine of Willemin, who maintains that biliary lithiasis, like urinary 
lithiasis, depends on the uric acid diathesis, it is none the less true 



DISEASES OF THE DIGESTIVE SYSTEM. 531 

that we find more cases of biliary calculi among the arthritic than 
among any other classes of people. Heredity seems also to play a 
prominent part in biliary lithiasis. Pepit and Willemin cite exam- 
ples, as also do Budd and Fauconneau-Dufresne. Senac, in study- 
ing the family health and constitution of patients who have con- 
sulted him, has so often met with different manifestations of the 
arthritic diathesis, that he believes this diathesis to be an important 
factor in biliary lithiasis. To the support of this view, he brings 
forward a certain number of observations which seem to place the 
matter beyond all doubt. Beneke has also set forth the relation 
which exists between atheromatous degeneration of the arteries and 
biliary lithiasis. He has found that in three-fourths of his cases 
(350 autopsies made by him at Marbourg) there was atheromatous 
degeneration of the arteries along with biliary lithiasis. To sum up, 
all the facts go to prove, as Bouchard has well shown, that the cause 
of biliary calculi resides essentially and primarily in a general dis- 
turbance of nutrition. 

"We know now the causes which are operative in the formation of 
calculi, and we have studied the anatomy of the bile-ducts. Let us 
now consider the mode of passage of gall-stones in the different ducts, 
and the accidents which may result from their presence. In the 
immense majority of cases, calculi form in the gall-bladder ; this is 
where the major part of the bile accumulates and sojourns ; never- 
theless, in certain circumstances, true biliary gravel has been known 
to be deposited in the hepatic bile-ducts, and to manifest its presence 
in the radicles of the hepatic duct and in the hepatic duct itself. 
But such facts are exceptional ; ordinarily the calculus, when formed 
in the gall-bladder, may increase in size and remain there a long time 
without determining any symptoms, and this is so true that at the 
autopsies of the aged women at the Salpetriere, it may be said that 
this is the rule to find in the gall-bladder calculi more or less volumi- 
nous, without any disturbance having been noted during life therefrom. 
But at other times, calculi of little size pass with the bile into the 
cystic duct and thence into the ductus choledochus, and are voided 
by the intestine. These calculi may make their journey from the 
gall-bladder to the intestine without causing any attack of colic, and 
in my own practice I observed several years ago a very curious 
instance in one of my patients who had been passing by stool a con- 



532 THE PRACTICE OF MEDICINE. 

siderable quantity of biliary gravel without ever feeling any colicky 
pains. At the same time there generally ensues an aggregate of 
painful symptoms described under the name of hepatic colic. In 
1873, I made, with Dr. Audige, numerous experiments in order to 
obtain a clearer understanding of the way these gall-stones pass 
through the biliary passages. We first of all discovered in animals 
that the bile-ducts when irritated are the seat of a real spasm, which 
is, moreover, easily explained, if you recall to mind the anatomical 
structure of these ducts. Then we artificially reproduced the attack 
of hepatic colic, for after having introduced into the common bile-duct 
of dogs by the intestinal opening certain foreign bodies, we observed 
the extreme sensibility of these conduits in these animals and the 
mode of passage of the calculi, which by reason of the spasmodic 
movement of which the ducts are the seat, travel either towards the 
intestine or gall-bladder. This is a fact of capital importance, which 
even justifies the affirmation that when, in persons affected with bil- 
iary colic, you do not find the offending body — the corps du delit — 
in the stools, you should not at once conclude that the calculus does 
not exist, and make the diagnosis of hepatalgia. It may happen, in 
fact, that the calculus, after having traversed the ductus choledochus 
a part of the way towards its intestinal opening, shall return to its 
starting point and fall back into the gall-bladder. These experi- 
mental researches, which have since been confirmed by Laborde, 
demonstrate that in hepatic colic there is a veritable painful spasm 
of the bile-ducts. Trouseau's penetrating mind understood this spas- 
modic action of the bile-ducts. In the very faithful description 
which he has given in his u Clinical Medicine " of hepatic colic, he 
speaks of the ejaculation of bile into the intestine, and assigns a 
considerable role to the muscular layer of these ducts. Senac, how- 
ever, the author of a remarkable study on the treatment of hepatic 
colic published in 1870, has most clearly shown the importance of 
these spasms. Hence, from the point of view of general pathology, 
there is good warrant for placing the acute accidents determined by 
the passage of gall-stones through the excretory ducts of the liver in 
the great group of colics, which, as you know, are properly defined 
as the painful contractions of mucus tubes which have a muscular 
layer. When a gall-stone is formed, either it produces no marked 



DISEASES OF THE DIGESTIVE SYSTEM. 533 

symptoms, as I have before said, or it gives rise to two orders of 
phenomona, viz.: the acute painful symptoms of hepatic colic, or, as 
is sometimes the case, a train of obscure symptoms with slow evolu- 
tion and often of difficult diagnosis. Sometimes there is an inflam- 
mation of the bile-ducts and gall-bladder sufficiently intense to give 
rise to peritonitis of a more or less spreading character ; in other 
cases less well known (and it is for this reason that I mention them), 
the pain is so severe as to produce lipothymia and fatal syncope. 
Hepatic colic may be preceded by prodromes, vague pains, cramps of 
the stomach, weight in the hepatic region ; but often it begins sud- 
denly by a pain which appears with or without appreciable cause, 
several hours after a meal. This pain rapidly attains its maximum. 
It is atrocious, paroxysmal ; it compels the patient to cry out. Accord- 
ing to Durand-Fardel, the maximum of this pain is in the right hypo- 
chondriac region ; according to Senac, on the contrary, it is in the 
epigastrium, and it is from this region that the pain radiates to the 
sides and posterior part of the body, to the vertebral column, to one 
or both shoulders, etc. The patients are taken with extreme rest- 
lessness; they do not find any comfortable position in bed. There 
is one position to which Durand-Fardel calls attention, which they 
seem to prefer, viz.: the sitting posture, with the body bent forward, 
the head resting on the knees. At the beginning of the paroxysms 
you sometimes observe a severe chill, epigastric distress, with ver- 
tigo, nausea, and vomiting, first of food, then of bile : sometimes 
also the patients may have convulsions, hysterical attacks, etc. 
Coincidentally with the first attack jaundice may appear ; it is, how- 
ever, sometimes wanting, especially in mild cases ; it is variable both 
in intensity and extent, may remain limited to the sclerotics, to the 
circumference of the nose, or mouth, or may invade the whole body. 
During the entire attack, you observe little or no change in the 
pulse and temperature. Pressure over the liver is painful, and it is 
with difficulty that by palpation and percussion you can detect con- 
gestion of the organs. After the attack, the patients suffer from 
general lassitude, which is in ratio of the intensity of the attack ; 
there is often, also, want of appetite, nausea, and vomiting ; the 
bowels are always constipated ; the urine is of deep wine color, and 
contains the coloring matter of the bile. 



534 THE PRACTICE OF MEDICINE. 

"Out of one hundred observations, Senac found sixty-five in which 

the only symptoms were of a gastric order : 

Cramps of the stomach 26 

Gastralgias 26 

Dyspepsia ... 19 

Pain in the epigastric region and in the back .... 3 

Pain in the stomach and liver 3 

Hepatic pains 7 

Sudden onset of the affection by well-marked hepatic colic 15 
Cases where the existence or absence of prodromes was 

not mentioned 7 

Too 
" To these gastralgic phenomena we may add another symptom 
quite as characteristic, namely, the appearance of remittent febrile 
attacks. Senac, who is so excellent an authority on these subjects, 
has shown that these intermittent attacks appear between 4 and 6 
o'clock in the afternoon. They are accessions of little intensity, but 
in some cases, as Charcot has pointed out, they may take on the char- 
acter of real pernicious paroxysms like those seen in the worst forms 
of malaria. We have here something very similar to what takes 
place in connection with states of the urinary passages when you 
catheterize certain individuals. You well know that febrile attacks 
of an intermittent character are often thereby provoked. It is the 
same with the bile-ducts, where the presence of foreign bodies is the 
occasion of similar reflex symptom. I can affirm the reality of these 
facts ; so whenever you have a patient with the symptoms of painful 
dyspepsia, in whom you observe a slight febrile movement coming 
on between 4 and 5 o'clock in the afternoon, especially if you notice 
a slight jaundiced hue which may be scarcely appreciable ; moreover, 
if you find the region of the gall-bladder sensitive and pain produced 
on pressure, you are warranted in affirming the presence of gall- 
stones. (Dujardin-Beaumetz on Diseases of the Liver.) 

One of the most interesting and practical of the papers that have 
recently appeared treating of gall-stones is by Dr. Seymour, of Troy, 
N. Y., who was a victim to this disease and was successfully oper- 
ated on by Dr. Tait. He watched the symptoms in his own case, 
with some interesting results. The attacks of pain were preceded 
several days, he says, by clay-colored stools, which continued several 
days after. In some instances, however, bile appeared in the stools 
an hour after an attack. He observed jaundice but twice in his case, 



DISEASES OF THE DIGESTIVE SYSTEM. 535 

although he had several hundred attacks. Jaundice need occur only 
when the duct is completely obstructed. He did not have the shoul- 
der pain, and thinks it of slight diagnostic importance. I do not 
think so, for nearly half my cases have had it. He also observed 
that the gall-bladder was tender on palpation several days before 
an attack. His observation that the pain is generally in the epigas- 
trium accords with my experience. Dr. Tait operated for a con- 
tracted gall-bladder, and besides some grit found 114 stones. 

Osier's experience, relating to the remittent chill and fever con- 
nected with gall-stones, is similar to that of Senac. Theirs was hos- 
pital experience. It is only when there is suppurative inflammation 
of the gall-ducts that this fever appears. In nearly one hundred 
cases of gall-stones I have met with it but twice. Next to mor- 
phine and atropine, Dr. Seymour values dioscorea as a palliative of 
the pain. He found relief from hot baths, which is the general 
experience. 

Treatment of Gall- Stones. — The treatment should fulfil the three 
following indications : 

(1) To meet and allay the symptoms caused by the presence of 
the calculus. 

(2) To attempt the solution of the calculus. 

(3) To prevent their formation. 

Treatment of the Colic. — The question here arises, Should we 
treat the colic at all ? The reflex and painful symptom of the colic 
are caused by the passage of calculi through the gall-ducts ; this pas- 
sage is necessary ; it is the only natural means of getting rid of the 
trouble. We might ask the same question relating to the passage 
of renal calculi through the ureters, or the passage of the child 
through the genital passage during labor. If we understand by the 
phrase " treating the colic," to oppose the passage of the calculus 
and its movements towards the intestine, the answer would be, No, 
just as it would be wrong to oppose the passage of the child out of 
the uterus. But if by " treating the colic " is meant to render the 
transit of the calculus as easy and painless as possible, we should 
certainly try to do so. I believe the opinion of all schools is fav- 
orable to methods and medicines directed towards this result. 

The question is, What shall we do ? I believe nearly all the old 
school, and many of ours, have decided that there are three great 



536 THE PRACTICE OF MEDICINE. 

therapeutic agents to be employed : (1) morphine and atropine, (2) 
chloroform, (3) antipyrine. In our school belladonna, cinchona, 
calcarea, hydrastis, and nux vomica. 

Morphine and Atropine. — This combination seems to be the best 
for the relief of the agonizing pain and spasm of the ducts. The 
best method is by hypodermatic injection, because it acts quicker, and 
causes few if any unpleasant symptoms. The dose may be as low 
as one-fourth of a grain of morphine and one-hundredth of a grain 
of atropine. Relief will be experienced in fifteen or twenty min- 
utes, and the dose may not have to be repeated. Curiously enough 
this method has met with the determined opposition of Senac, an 
eminent French old-school physician. His argument against it is 
the same as that of its opponents in our school, namely : " The con- 
traction is necessary to the transit of the gall-stone, and by morphine 
injections you hinder the passage of the calculus into the intestine, 
and thus you retard the cure of your patient." Per contra, Dujar- 
din-Beaumetz, who has had an immense clinical experience, says : 
" Never (and I emphasize the word never), in innumerable cases of 
hepatic colic have morphine injections appeared to prolong colic, and 
relief from pain is always obtained. The explanation seems simple 
enough. We recognize the fact that morphine, like atropine, 
opposes, to a certain extent, spasm of unstriped fibres, but who will 
say that when this spasm exceeds certain limits, instead of favoring 
the passage of the calculus it does not arrest it in its course by excess 
of contraction ? " Remember that this injection should be reserved 
for cases of great intensity, just as we often reserve chloroform for 
cases of painful labor, in which the uterine pains are so violent and 
tetanic as to hinder the birth of the child. 

Chloroform often gives great relief in the violent spasmodic pains 
of gall-stone colic. Give it as follows : from ten, twenty, or thirty 
drops on a handkerchief, and let the patient inhale it, ceasing when 
the spasm is mitigated, and repeating the inhalation as often as it 
returns. I have seen good results from chloroform water, a teaspoon- 
f ul every ten or fifteen minutes. One of my most intractable cases 
got more relief from chloroform water and phosphate of codeine, 
one-tenth of a grain of the latter to each teaspoonful of the former, 
a teaspoonful every fifteen minutes. After three or four doses the 
pain always subsided. In a few cases I have injecte'd hypodermat- 



DISEASES OF THE DIGESTIVE SYSTEM. 537 

ically one-half of a grain of phosphate of codeine with good effect. 
It is useful, when, from idiosyncrasy, morphine is not well borne. 
Germain See praises hypodermatic injections of antipyrine, but it is 
not now favorably considered. The preparation known as chloro- 
dyne, in doses of fifteen drops, repeated if necessary in half an hour, 
is a favorite with English physicians. In cases where the shock of 
the pain causes fainting, collapse, and coldness, I would recommend 
inhalation of amyl, or a dose of glonoine, one-fiftieth or one-hun- 
dredth of a grain on the tongue. Remember that the above ano- 
dynes are for violent cases where relief is urgently demanded, and 
we feel obliged from motives of policy or humanity to accede to such 
demands. 

These attacks of colic may come on regularly or not, and may 
simulate dyspeptic pains coming on after eating. If the calculus is 
expelled from the duct the pain ceases immediately ; but if the spasm 
relaxes without expelling the stone, the pain ceases gradually. Now 
as to the treatment of our school. I know of no homeopathic med- 
icine that will give immediate relief. I know that in many cases 
immediate relief from the pain has occurred while the patient was 
taking belladonna, nux vomica, and other medicines in attenuated 
doses, but we do not know that the medicine given caused immedi- 
ate relief. The relief was caused by the escape of the stone from 
the duct, which may occur under all circumstances, unaided by any 
drug. We are all glad to have our patients believe that the medi- 
cine gave them prompt relief, but we should not report these cases 
as proof of its effect. Medical reports are too full already of these 
false assertions. I have in my mind several reports of rapid relief 
in hepatic colic, from calcarea carbonica 200th, belladonna 30th, 
and cinchona 30th. This last medicine was highly vaunted by Dr. 
Thayer, of Boston ; his selection of this medicine being based on the 
periodicity of the attacks ; but I do not consider such an indication, 
in hepatic colic, of any value whatever. 

Dr. Burnett, in his " Greater Diseases of the Liver," reports 
many cases of hepatic colic. He says of hydrastis that he has found 
it the best of remedies for gall-stone colic. He gives ten drops of 
the tincture in hot water every half hour, and has known it to suc- 
ceed after everything had failed. " In one case the patient had lain 
for forty hours in terrible agony, unrelieved by any known thing." 



538 THE PRACTICE OF MEDICINE. 

The colic ceased while he was taking Hydrastis ; but did the medi- 
cine expel the stone, or was it just on the point of being expelled ? 

Myrica cerifera he thinks cured a case of hepatic colic " in a 
week." Chelidonium perhaps has the highest claims of all as an 
aid in the expulsion of gall-stones. It was Kademacher's great gall- 
stone remedy. Buchner reports many cases of gall-stones expelled 
under its administration. I find no reports of immediate relief of 
hepatic colic from its use, but there is ample proof that it aids in 
the expulsion, and prevents their formation. I believe this is due 
to its peculiar action on the hepatic cells, causing them to secrete a 
thinner and more profuse bile. I have treated many intractable 
cases when the stones had remained in the duct several months, — in 
one case a year, — and when the icterus was intense, the whole body, 
eyes, tongue, lips, and vagina, had assumed a greenish yellow hue. 
Several of these cases did not improve until chelidonium was given, 
and under its use the calculi were discharged. In one case the stone 
was an inch and a half long, and half an inch in diameter, and in 
shape like a dumb-bell. In two cases which simulated pernicious 
intermittent, in which the paroxysms of pain and fever occurred 
every evening, and quinine had been given before I was called, gel- 
semium arrested the paroxysm. A colleague who consulted me for 
a similar case tried Dr. Thayer's cinchona 30th without results, but 
succeeded with gelsemium. 

Dioscorea was a favorite remedy for bilious colic with the early 
botanies and eclectics, and I have seen apparent benefit from its use 
in infusion and decoction. I was surprised to find that Professor 
Goss, in his " Practice," does not mention it in this disease. He 
mentions it in spasmodic and flatulent colic, and the action of the 
drug in such cases ought to make it a remedy for spasm of the gall- 
ducts. Berberis has some reputation, but I have never tested it. 

Olive Oil. — This oil was recommended for the treatment of gall- 
stones by one of our school about thirty years ago. I first used it 
in 1866, in the case of a young woman who had been jaundiced for 
nearly three months, during which she had suffered from violent 
attacks of hepatic colic. Nearly every indicated remedy had been 
used without removing the impaction. I ordered at night a teacup- 
ful of oil. The next morning she passed several gall-stones of the 
size of playing marbles. When broken they presented a beautiful 



DISEASES OF THE DIGESTIVE SYSTEM. 539 

stellar crystalization. A prompt and permanent recovery followed. 
Since that time I have prescribed it with varying results, often cur- 
ing many cases of long standing and as often failing in others. The 
cause of these failures cannot be explained. 

The value of this oil is disputed by some. Osier says, " Olive 
oil has proved useless in my hands." But his experience, if we are 
to judge by his book, has been mainly in hospitals, and not so much 
with simple impaction as inflammation of the gall-ducts. Another 
cause of doubt in its efficacy is that the greenish-yellow masses, from 
the size of a pin-head to a grape, which appear in the stools after 
taking the oil, are not really calculi or biliary concretions, but are 
composed of saponified oil and contain no cholesterine. Doubtless 
many of the reported cases of supposed expulsion of gall-stones from 
the administration of the oil were based on these pseudo-concretions. 
Quacks and charlatans have made use of these oily masses to con- 
vince patients of their skill. Dr. Porter, of St. Louis, sums up his 
arguments against the oil as follows : " (1) The mucous membrane 
of the biliary ducts cannot be coated with oil. (2) No positive 
diagnosis of gall-stones can be made unless the stone is found in the 
faeces." To this I reply that the oil can enter the gall-bladder by 
capillary attractions through the common duct, and that there are 
undeniable cases on record of veritable gall-stones found in the stools 
soon after taking the oil. 

Professor Germain See, whose opinions few will care to dispute, 
is a firm believer in the efficacy of olive oil in the treatment of gall- 
stones, and explains its action by supposing that the fatty acids con- 
tained in it dissolve the cholesterine of the gall-stones. Dr. Rosen- 
berg reports the following case : "A patient suffering from marked 
biliary colic, that had continued for five years, and had proved refrac- 
tory in spite of all treatment, including a ' Trinkkur ' in Carlsbad, 
and in whom the pain was very acute, was given a dose of 100 
grammes of olive oil (about three ounces) at night. In the morn- 
ing there were found in the stool three concretions, one the size of a 
grain of linseed, the other two smaller. Some days later a second 
dose was given of 180 grammes, and in the stool that followed 180 
concretions were found, varying in size from a pin-head to a hazel- 
nut, and after a third dose 243 stones. The patient's troubles soon 
after this began to diminish, but they did not entirely disappear. 



540 THE PRACTICE OF MEDICINE. 

She took in all, in five doses, 820 grammes of olive oil, and 629 
stones were counted in the evacuations that followed. The gall- 
bladder, which before was the size of the fist, and projected beyond 
the edge of the liver, diminished so far that it could be no longer 
palpated. It was assumed that the oil did not act by exciting per- 
istalsis of the intestines, but by passing directly into the gall-bladder 
and softening the contents." Now it is not supposable that an edu- 
cated medical man could mistake rounded masses of saponified fat 
for gall-stones ; and, besides, the change effected in the gall-bladder 
would be proof, without finding the stones. Drs. Mayo and Bloom, 
of Philadelphia, received in answer to circular letters inquiring for 
cases of gall-stones treated with olive oil, reports of thirty-seven 
cases. An analysis of these cases seem to show the positive value 
of the oil. I do not know that it is necessary to use pure olive oil ; 
perhaps any vegetable oil would be as good, and possibly better. I 
would suggest a trial of cotton-seed oil, peanut oil, sunflower oil, the 
oil of sweet almonds, and other oils. 

If further proof is wanted of the value of oil, Dujardin-Beau- 
metz, in one of his papers on the treatment of gall-stones, writes as 
follows : 

" But I desire to call your attention particularly to a new medic- 
inal agent — I refer to olive oil. It is to the homeopathic physicians, 
who have, it must be admitted, introduced a number of new medi- 
cines into the materia medica, that we are indebted for our knowl- 
edge of the utility of olive oil, given in large doses, as a remedy for 
hepatic colic. It is now almost twenty years that this treatment ha& 
been in vogue. In recommending olive oil in this affection, it might 
seem that they were in part faithful to their doctrine, in combating 
gall-stones constituted essentially of cholesterin, a fatty body, by an- 
other fatty body, — 'similia similibus.' At the same time, note that 
they employed it in large doses, which is hardly consistent with the 
Hahnemannian doctrine. 

" From the United States, this method passed over to England r 
and was there adopted by several regular physicians, and among 
them Kennedy, Thompson, and Singleton Smith. In France it was 
not till after the publication of Touatre in 1887, that we commenced 
using this remedy, and Chauffard and Dupre, in 1888 ; Martial 
Durand, of Bordeaux, in 1889 ; Huchard, Germain See, and Mar- 



DISEASES OF THE DIGESTIVE SYSTEM. 541 

ciguey, in turn published favorable results. All these clinical facts 
have, moreover, been summed up in an excellent paper by one of 
my pupils, Dr. Willemin, of Vichy, from which I borrow the more 
important points respecting this mode of treatment. To-day the 
facts are sufficiently numerous to warrant us in affirming that olive 
oil in large doses is one of the best means of combating the painful 
phenomena determined by the presence of calculi. It arrests almost 
instantly the severe acute pains, and diminishes considerably the 
period during which the patients suffer dull pains, prostration, and 
discomfort. Failure constitutes the exception, and what is strange, 
the large quantity of oil is well borne and the patients do not vomit. 
I say large quantity, for you must give in one dose 200 grammes 
(or nearly a tumblerful) of pure olive oil, and, in order to do away 
with its disagreeable taste, you can order the patient to rinse the 
mouth with brandy and water, or to suck a little orange juice. In 
my own practice, to the olive oil I add bile, and with 200 grammes 
of oil I combine twenty grammes of ox-gall. This mixture is slightly 
bitter, but it is well tolerated by the patient, and the results have been 
the same as with the oil, so that it is difficult for me to credit to the 
bile what really belongs to the oil in these cases. I was led to 
employ ox-gall by the researches of Provost and Binet, who have 
shown that this substance is a powerful cholagogue. We are still 
ignorant of the real mechanism of the therapeutic action of olive oil. 
Touatre maintains that the oil always causes expulsion of the cal- 
culi. We know to-day the cause of this mistake. Touatre con- 
founded with gall-stones certain oily concretions resulting from the 
incomplete digestion of the ingested oil. It is difficult to admit 
that the oil acts directly on the calculi, for we cannot conceive of its 
passing into the bile-ducts. Stewart maintained that the oil broke 
up into fatty acids and glycerine, and that the latter produced in the 
intestines reflex movements favoring the issue of the calculus. Others, 
and in particular Rosenberg, considered the oil as a powerful chola- 
gogue, and it is this cholagogue action which explains the favorable 
effects of the oil. Lastly, we may suppose that the oil has a direct 
action on the orifice of the ductus communis choledochus and cor- 
responding duodenal region, which tends to diminish the reflex 
spasm, which is the first cause of the colic. For my part, I am 
ready to adopt the opinion of Willemin, who thinks that the large 



542 THE PRACTICE OF MEDICINE. 

doses of oil act in several ways : first, as a cholagogue, then in dimin- 
ishing the reflex action, and lastly in favoring the descent of the cal- 
culus into the intestine by their laxative properties. However this 
may be, the number of favorable facts is to-day so considerable that 
before having recourse to the injections of morphine, you ought to 
always make your gall-stone patients take a full dose of 200 grammes 
of olive oil, with or without the addition of the ox-gall." 

Glycerine. — Dr. Ferrand (" Le Bulletin Medicale," No. 20, 
1892), induced by the ease in which glycerine dissolves various sub- 
stances, and especially the majority of coloring matters, tried it in 
the treatment of cholelithiasis. 

"Experiments, however, have proved that the drug is not lithotrip- 
tic, yet, used in practice, it has shown itself to be a precious remedy 
in the treatment of gall-stones. If administered during the attacks 
it causes them to disappear rapidly. Experiments on animals have 
demonstrated that glycerine, given in small doses, is well borne by 
the stomach, is soon absorbed by the gastric mucous membrane, and 
enters into the lymphatic circulation without difficulty. From here 
it gains the lymphatic plexus of the liver and gall-bladder, causing 
a copious secretion of liquid bile, with which the gall-stones are 
swept out. Glycerine leaves the liver through the blood-vessels, as 
many experiments have demonstrated. Hence it is a true chola- 
gogue, and indeed a direct one, as it penetrates into the liver through 
the lymphatic vessels, and by the same route is poured into the gall- 
bladder. It exercises here, as well as in the liver, its characteristic 
hydroscopic action. A comparison of its action with that of olive 
oil is of interest, for this latter has long been used successfully in 
cholelithiasis. The action of the oil may be due to its decomposi- 
tion into fatty acids and glycerine. This latter is the substance 
which acts in promoting the secretion of bile. Therefore it is better 
to give glycerine itself instead of the oil, as its action is more direct, 
surer, and can be more certainly dosed. The employment of glycer- 
ine varies. If one desires to abort an attack of gall-stone colic, 
twenty to thirty grammes (five drachms to one ounce) will be found 
sufficient, and may be repeated for several days in succession, which, 
however, is seldom necessary. During the attacks it may be given 
every morning in doses of from one to three teaspoonfuls in a half a 
glass of some alkaline water. Larger doses are best given in cherry 



DISEASES OF THE DIGESTIVE SYSTEM. 54S 

laurel water, to which twenty-five to thirty grammes (six drachms 
to one ounce) of chloroform water are added, which latter exercises 
a sedative action on the gastric mucous membrane. To this any 
syrup may be added, and the mixture is given by the teaspoonf ul 
every hour, or it may be administered in larger portions. Even if 
given for a long time, glycerine does not have any injurious action ; 
on the contrary, it prevents the usual constipation from the alkaline 
water." 

The Solvent and Preventive Treatment. — There are some rem- 
edies that have a reputation as solvents of calculi in the gall-bladder. 
But many authorities deny the possibility of such an action. The 
most popular remedy, especially in France, is the mixture of turpen- 
tine and ether, half a teaspoonful every morning, or every night and 
morning. This mixture is so repulsive to most patients that Trous- 
seau advises giving one capsule of turpentine (fifteen drops) and 
two of ether (thirty drops) several times a day. Several years ago 
I tried this in some cases, but could see no beneficial results. Dujar- 
din thinks it had better be discarded as well as the terebin thin ate 
soap of Durand. Choleate of sodium and the succinate of iron is 
highly praised by Buchler, of Baltimore, Md., and many physicians 
claim to have given it with benefit. 

The plan I recommend, while the medicines are not themselves 
solvents, are agents which modify the character of the bile. These 
medicines, namely, that cause the hepatic cells to secrete thin and 
normal bile, which prevents the formation of calculi. The medicines 
having such action are chelidonium, carduus, iris versicolor, euony- 
min, and natrum sulphuricum. 

Chelidonium causes the liver to secrete thinner and a more pro- 
fuse yellow bile than any other drug. No one can read the provings, 
the clinical experience of Rademacher, Burnett, and many others 
without being convinced of this, and of its great influence for the 
prevention of biliary calculi. In many cases I have greatly aided 
the expulsion of gall-stones by its use ; the thin, profuse biliary secre- 
tion caused by it washing them away. The dose need not be large, 
in fact very large doses of this as well as of all cholagogues cause a 
suspension of the bile-secreting process. 

Rademacher, who was one of the first to use chelidonium (although 
it has been used in domestic practice in Germany for centuries), gave 



544 THE PRACTICE OF MEDICINE. 

very small doses, one drop five times a day in most cases. He says 
he gave at first thirty drops, but found from experience that smaller 
doses acted better. The tincture he used was made of the expressed 
juice of the plant and alcohol, equal parts. Burnett gives material 
doses, five to ten drops several times a day, for gall-stones. It is 
proper to use the 3x or 6x dilution for bilious diarrhoea, or acute 
congestion of the liver, for in such cases we have its primary action, 
which calls for minute doses. 

Carduus has a similar action on the liver, but it cannot be sub- 
stituted always for chelidonium because its concomitant symptoms 
are different. The dose is the same as that of chelidonium. 

Iris versicolor and its active principle iridin, causes very thin, 
yellow bilious discharges, with vomiting of the same. I believe I 
have prevented the recurrence of gall-stones many times by its con- 
tinued use. The most efficient dose for this purpose is five to ten 
drops of the lx or tincture, or a grain of the lx or 2x of iridin, 
several times a day. The headache and acid condition of the secre- 
tions of the digestive tube are the chief indications. 

Euonymin seems to be preferred by European physicians. Dujar- 
din and See recommend it highly, because it does not irritate the 
stomach or cause diarrhoea. They give one grain at night, which 
may act as a slight laxative. I prefer the lx trituration, giving one 
grain (in tablet) three or four times a day, before meals and at 
night. It is especially indicated when, with or without the jaundice, 
there is a stupid headache, generally in the occiput, the urine being 
saturated with uric acid, and the digestion bad. Podophyllin, myr- 
ica, hydrastis, juglandin, aloe, sanguinaria, leptandrin, thaspium, and 
Phytolacca may be indicated if their guiding symptoms are present. 

Prof. Germain See, of Paris, praises salicylate of sodium, not 
only for the prevention of biliary calculi, which it does by " augment- 
ing the watery part of the bile," but as an analgesic remedy during 
the paroxysms of pain. 

Phenacetin is much better for the pain. We do not know how 
it acts upon the secretory functions of the liver, probably not at 
all, any more than does antipyrin, antifebrin, or others of that class. 

Dr. Burnett is very likely the first to use thaspium bursa pastoris 
in biliary calculi. He says it quickly relieves the pain, and may 
dissolve the biliary, as it does renal calculi. He insists that it is 



DISEASES OF THE DIGESTIVE SYSTEM. 545 

indicated " when the original liver ailing started in the womb." 
Perhaps it would be better to say when the biliary alternated with 
renal calculi, as is often the case. 

Dujardin-Beaumetz says : " The really curative treatment of bil- 
iary lithiasis is the thermal treatment, i. e., by the natural alkaline 
waters ; and there are two spas especially the waters of which are 
efficacious in these cases : I refer to Vichy and Carlsbad." Mor- 
gan (in " Diseases of the Liver ") recommends them in connection 
with homeopathic treatment — and very properly, as they aid greatly 
the action of the indicated medicine. All medical authorities agree 
that these and similar waters do not act by dissolving the calculus, 
but by regulating the digestive function, diminishing the hepatic 
congestion, and by modifying the bile itself. Foreign physicians 
seem to select the water to suit certain conditions of the patient. 
They advise Vichy to some because of the large quantity of bicarb- 
onate of sodium it contains. The "Hospital" Spring is preferred 
for biliary lithiasis — a tumblerful four times a day. Other patients 
they advise to take Carlsbad on account of the sulphate of sodium 
(natrum sulph.) it contains. The " Sprudel " is preferred. 

In this country we have waters which resemble both ; the Con- 
gress of California, Saratoga, and Lansing resemble Vichy. The 
saline springs of Virginia and Florida, and the " Carlsbad " of Col- 
orado. The imported powdered Carlsbad salts are composed mainly 
of sulphate of sodium and bicarbonate of sodium, and, when taken in 
connection with proper diet and medicines, are as efficient here as 
Carlsbad water is. In most cases I advise a teaspoonful of Carls- 
bad salts in the morning in hot water, and fifteen grains in hot water 
before meals. If the stomach is acid all the time, I advise a glass 
of Vichy after meals. 

In many cases I prefer the phosphate of sodium to either of the 
other sodium salts. It removes acid indigestion, thins the bile, mak- 
ing it profuse and alkaline, and has some tonic effect on the ner- 
vous system which the others have not. One drachm in the morn- 
ing before breakfast, and ten grains before or after meals, is the most 
efficient dose. 

The diet is the same as that recommended for lithasmia. Sugar 
or starchy foods in small quantities. Fatty foods, especially bacon 
and butter, in moderate quantities. Milk, while advised in simple 

35 



546 THE PRACTICE OF MEDICINE. 

jaundice, is not advised in this condition. The dry crust of bread 
or zwiebach is preferred to bread. No new bread should be eaten. 
Eggs and meat in small quantities. Fresh vegetables and legumes 
are advised, and all acid fruits except tomatoes. 

The "grape cure" is credited with curing some cases. Acid 
fruits change in the stomach to alkaline compounds, and all alkalies 
prevent that undue acidity of the bile which leads to the precipita- 
tion of cholesterine. As an excess of cholesterine shows a breaking 
down of the nervous system, all intense mental emotions or nervous 
strain should be avoided. All fresh fish, except shell fish, may be 
eaten. All liquors, except the dryest wines, and all high-seasoned 
soups and other dishes should be avoided, as they tend to cause 
catarrh of the stomach, extending to the ducts, where it has a ten- 
dency to lead to the formation of calculi, by arresting the free flow 
of bile. Active exercise in the open air, and the wearing of wool 
garments next the skin all the year, are indispensible aids to a cure. 

Dr. W. C. Van Biber reports five cases (Trans, of the Medical 
and Chir. Faculty of Md.) to show that choleate of sodium may 
act as a substitute for the bile when this secretion does not enter the 
duodenum. This he considers to be most desirable in cases of chronic 
jaundice. In these cases the use of the remedy improved the diges- 
tion, and the author's theory is that it acted as a substitute for the 
bile. In none of the cases did an attack of the colic occur during its 
administration. He recommends choleate of sodium in certain cases 
of dyspepsia, dependent on functional derangement of the liver ; and 
in chronic jaundice, when it is evident that a sufficient amount of 
bile is not poured into the duodenum. In the former he considers 
that it will be quite as serviceable as pepsin is in other forms of 
indigestion, on the principle of supplying a substitute for a physio- 
logical secretion. He refers also to the use of the choleate, as pro- 
posed by Dr. Dabney, as a preventive of the formation of gall-stones. 

Note I have named the European Carlsbad water; the American Carls- 
bad of Colorado; and all springs containing sulphate of sodium (natrum sulph.) 
as best suited for lithsemia, gout, and gall-stones. The European Carlsbad con- 
tains twenty-five grains to one pint; the Colorado, ten grains. Of carbonate of 
sodium, the European Carlsbad contains seventeen grains; the French Vichy, forty- 
seven grains; the Saratoga Vichy, ten grains; the Colorado Carlsbad, one-third of 
a grain; the Vichy of California, twenty-five grains; the Pacific Congress springs of 
California, fifteen grains. These two last most nearly resemble the French Vichy. 



DISEASES OF THE DIGESTIVE SYSTEM. 547 



ACUTE HEPATITIS. 

This is a very rare disease in temperate climates. It sometimes 
occurs in our Southern States, is frequent in the West Indies, espe- 
cially among Englishmen, who do not conform their habits of life to 
suit the climate. It is frequent also in India, and it is from the 
physicians of that country that we get the most accurate accounts of 
the disease. Some of the causes are blows on the region of the liver, 
indigestion, rapid chilling of the body while sweating, sudden sup- 
pression of perspiration by excessive drinking of or bathing in cold 
water, etc. 

Dutrouleau, who gives the best description of the disease, says : 
" The endemic hepatitis of hot climates passes through different 
stages which have their distinct characters. To the three anatom- 
ical characters, congestion, inflammation, suppuration, correspond 
certain symptoms which give to the disease a special physiognomy. 
To the form which is the most mild has been sometimes given the 
name of the dominant symptom, " liver ache " (point de cote) ; the 
denominations and acute chronic hepatitis indicate the disease arrived 
at the stage of phlegmasia, corresponding to these two forms ; abscess 
of the liver indicates the disease gone on to suppuration." 

The pain in the side corresponds to active hyperemia. Some- 
times suddenly, after fatigues or excesses, the patient is taken with 
an excruciating pain in the right side, exasperated by pressure and 
strong inspirations. This pain by degrees becomes less, then disap- 
pears, to return after the least fatigue or excess. Sometimes the 
disease is confined to this one symptom, and the patient gets well ; 
if it continues its progress, it soon goes on to the second and third 
stages. Habitually, the hepatitis begins by an accession of fever 
with a chill, heat, and sweats ; then supervenes an excruciating, lan- 
cinating pain, which obliges the patient to writhe and draw himself 
up in his bed ; at the same times there is a considerable difficulty of 
breathing, which auscultation does not sufficiently explain. When 
the crisis is passed, the patient still experiences the pain, which is 
less intense, and which almost always corresponds to an inflamed 
point in the liver. Dutrouleau attaches a great importance in diag- 
nosis to a sympathetic pain which the patient sometimes experiences 
in the right shoulder, and which indicates an inflammation of the 



548 THE PRACTICE OF MEDICINE. 

convex surface of the organ. If the patient is to get well the pain 
little by little disappears, leaving only some soreness behind. If the 
disease passes to the chronic stage, the pain becomes intermittent, 
lancinating, while the fever becomes high if the hepatitis goes on to 
suppuration. Jaundice does not always exist after the crisis ; some- 
times there is a straw-yellow color of the skin, a simple icteric pallor, 
with slight discoloration of the sclerotics, the urine is red and scanty, 
and does not contain the coloring matters of the bile, except when 
the icterus is intense. When the hepatitis goes on to suppuration 
the liver becomes tumefied and protuberant, and sometimes bulging 
is detected at the point where the abscess is seated. Abscesses of 
the liver are superficial or deep, and are oftener seated in the right 
lobe than in the left (in 122 out of 136 cases). They differ from 
metastatic or pysemic abscesses, which have a brown color, are small, 
situated at the surface, and do not possess a pyogenic membrane. 
The abscesses of hepatitis are generally single. Out of sixty-six, 
Dutrouleau found forty-one in which there was but one ; sixteen in 
which there were two ; five in which there were three. Lastly, out 
of these sixty-six cases, there were fifty-six large abscesses, i. e., the 
size of an orange at least, and ten small ones. The pus of recent 
abscesses is brown, the color of wine dregs, sometimes contains blood 
or the debris of the organ; takes on an ammoniacal, sometimes putrid, 
odor. When surgical interference is not resorted to, the abscess, if 
not too large, may get well by absorption ; else it increases in size 
from day to day, and the patient, by reason of the progress of the 
disease, falls into a profound adynamia, and dies of exhaustion. 
Under other circumstances the pus dissects for itself a passage exter- 
nally, or into the neighboring organs, and if there are peritoneal 
adhesions, it may burrow its way through the abdominal walls ; in 
other cases it bursts into the peritoneal cavity, and causes a rapidly 
fatal peritonitis. If the abscess opens into the pericardium, death 
does not long delay, but if it opens into the bronchi, the stomach, 
or the colon, recovery may sometimes take place. Murchison relates 
such a case of recovery in a physician whose abscess opened into the 
bronchi. 

In temperate climates what is called hepatitis, or diagnosed as 
such, may be a pleurodynia, intercostal rheumatism, or pleurisy, 
which may simulate hepatitis in some of its superficial aspects. 



DISEASES OF THE DIGESTIVE SYSTEM. 549 

Abscess of the liver, so common in the tropics, rarely follows 
our simple hepatitis, but is usually the result of dysentery, the ulcer- 
ations in that disease determining the passage of septic matters into 
the portal circulation and the transference of these matters into the 
substance of the liver. 

The treatment of acute hepatitis with high temperature should 
commence with aconite, or veratrum viride. These will reduce the 
intense hyperaemia. Their use should be accompanied by copious 
hot enemata thoroughly to empty the bowels, or the administration 
of Carlsbad salts, until all morbid matters are washed out of the 
intestines. 

For the excessive pain never use any preparation of opium. If 
bryonia or chelidonium do not control it, give two or three grains of 
phenacetin or salicylate of sodium every hour. If the fever is inter- 
mittent, coming on in the morning, give eupatorium perfoliatum, gel- 
semium, or cedron ; if in the afternoon, from 4 to 6 P. M., cinchona 
or lycopodium ; quinine or ciuchona if the tongue is clean or cleaning. 

If extreme high temperature, chills, and sweats occur, denoting- 
suppuration, give hepar sulphur or hypophosphite of lime. It is 
often possible to prevent suppuration by these medicines. 

External applications of poultices, hot-water compresses, mustard, 
etc., may assist in relieving the pain. The treatment of hepatic 
abscesses belongs to the domain of surgery. They may break into the 
intestines, peritoneum, or into the lungs or pleura. Any physician 
not a surgeon should be ready to open an abscess if danger threaten 
from it. The aspirators of Dieulafoy or Patain can be used with 
safety. If in trying to puncture the abscess we do not happen to hit 
it, but puncture the substance of the liver, no bad result will follow. 
Physicians in India and in Europe, and in American hospitals, often 
puncture the liver in engorgements, and great relief follows the with- 
drawal of blood. I believe that veratrum viride, if cautiously and 
continuously used for a considerable time, will be more useful than 
any abstraction of blood. Give enough to keep the pulse down to 
60, and no unpleasant symptoms will result, while the amount of 
blood in the liver will be greatly decreased. 

Boldo will act well after veratrum viride, and may be able to pre- 
vent cirrotic hardening. The effective dose appears to range from 
three to fifteen drops of the tincture every four or six hours. 



550 THE PRACTICE OF MEDICINE. 

CIRROSIS OF THE LIVER (Chronic Interstitial Hepatitis). 

Definition. — A chronic disease of the liver cells, and an over- 
growth of connective tissue elements, in consequence of which the 
organ becomes hard and unusually small. It occurs most frequently 
in middle-aged males. 

The following are the causes : alcohol, syphilis, cyanotic conges- 
tion, malaria, tuberculosis, scarlet fever, rickets, and obstructions 
of the bile-ducts. The two most common causes are alcohol and 
syphilis. 

Yellow atrophy sometimes is a form of cirrosis. The liver may 
be so small as to weigh not more than one pound. Fatty cirrosis 
usually occurs in beer-drinkers. In the first stage of cirrosis the 
liver may be enlarged, but this is due to hyperaemia. 

Glissonian, Cirrosis or Perihepatitis. — This form is a conse- 
quence of an inflammation of Glisson's capsule, and is usually the 
result of hard drinking. The two essential elements in cirrosis 
are destruction of the liver cells and obstruction of the portal system. 

Symptoms. — The most extreme grade of atrophic cirrosis may 
exist without symptoms. This, says Osier, is due to a compensating 
circulation which may be established. So long as this compensatory 
circulation is maintained, the patient may suffer little or no inconven- 
ience. Osier describes the method by which this is obtained, mainly 
by anastomoses. 

In the obstructive variety the over-filling of the blood-vessels of 
the stomach and intestine leads to gastric catarrh, and the patients 
suffer with nausea and vomiting, particularly in the morning ; the 
tongue is furred and the bowels are irregular. When a man addicted 
to drink has these symptoms, the liver should be carefully examined. 
If he has occasional hemorrhages from the stomach or bowels, the 
case is more suspicious. Evidences of the collateral circulation 
are seen in the enlarged epigastric and mammary and hemorrhoidal 
veins. Then acites sets in unless the compensatory circulation obtains. 
The peritoneal dropsy becomes great, attended by oedema of the legs, 
rarely a general anasarca. There is sometimes jaundice ; the urine 
is reduced in quantity, and is full of urates, with occasional tube- 
casts and albumen. At first the liver is enlarged and painful on 
pressure. Later on, the patient has unmistakable " hepatic facies"; 



DISEASES OF THE DIGESTIVE SYSTEM. 551 

lie is thin, his eyes are sunken, the conjunctivae watery, the veins in 
the nose and cheeks are distended, and the complexion is muddy. 
On the abdomen are dilated bunches of veins — around the navel. 
The liver feels hard and granular, and the spleen is unusually enlarged. 
The patient may show toxic symptoms due to cerebral irritation, such 
as noisy delirium, stupor, coma, or convulsions, a condition often mis- 
taken for urasmia. In hypertrophic cirrosis the disease may continue 
a long time, and be mistaken for obstructive jaundice from gall- 
stones, but as a rule the stools contain a little bile. In the end, fever 
may set in with temperature from 102° to 104°, with dry tongue, 
rapid pulse, and petechias. 

Treatment. — It is not considered a curable disease. We know 
of no remedies which can remove the cicatricial tissue that has formed 
in the liver. It is possible that conium, barium, and iodide of gold 
may do this, but we have no absolute clinical proof. If the patient 
is seen in the early stage, and will abstain from liquor and improper 
food, I believe nux vomica, chelidonium, carduus, aurum, nitro-mu- 
riatic acid, euonymin, or podophyllin may arrest it. This treat- 
ment should be aided by an out-of-door life, and the use of Carlsbad 
or French Lick water. Burnett believes iodoform may have a cur- 
ative action. 

Boldo, a South American drug largely used by the natives, has 
been experimented with by Dujardin and Campenow. They believe 
it has a specific action on the liver, reducing hypertrophy and 
engorgement, and in a few instances curing cirrosis. Dr. Campe- 
now, in the " Rivesta Medica," writes that he had recently under his 
care two cases of cirrosis of the liver, characterized by increase of 
the volume of that organ, dilatation of the subcutaneous veins, and 
slight ascites, in which he attributes the cure to the use of boldo. 
He prescribes the tincture of the bark, five drops in a little water a 
few minutes after eating ; six drops are given the second day, and 
the dose is increased each day until fifteen or twenty drops are given 
at a dose. When the maximum is reached the dose is diminished 
daily until the initial dose of five drops is reached. This treat- 
ment, in order to cure, should be of long duration. 

Osier doubts the possibility of cures. He says : " The so-called 
cures of cirrosis means the re-establishment of a compensatory cir- 
culation, and it would be as unreasonable to speak of healing a 



552 THE PRACTICE OF MEDICINE. 

chronic valvular lesion, when with digitalis we have restored the 
compensatory balance, as it is to speak of curing cirrosis of the liver, 
when by tapping and other measures the compensation has in some 
way been restored." 

Pronounced ascites should not be allowed. It ought to be removed 
by tapping, if apocynum, diuretin, eupatorium, purpureum, or some 
similar drug will not act. In several cases I have kept the dropsy 
down by the use of Epsom salts, elaterium, jalap, and calomel 
(mere. dulc). In one remarkable case, when the patient was in a 
dangerous condition, the ascites and oedema of the legs were entirely 
removed by calomel, two grains every three hours. The urine, 
which was almost suppressed, increased enormously on the third day, 
after copious watery evacuations from the bowels, the man remain- 
ing free from the dropsy for a year, when a second attack was 
removed by the same means. Osier reports a case of syphilitic cir- 
rosis, in which tapping had been performed eight times : " The man 
was then given the Niemeyer pill of mercury, squill, and digitalis. 
He took this pill for a year with the greatest benefit, and subse- 
quently had four years of tolerably good health." 

Burnett (" Greater Diseases of the Liver ") records some cures of 
probable cirrosis of the liver, after the use of chelidonium, carduus, 
myrica, and leptandrin. 

Seminola insists upon a milk diet, abstinence from alcohol, and 
an out-of-door life. 

Phytolacca may be useful in cirrosis with fatty liver. Iodine has 
been recommended, but its value is now doubted. 



FATTY LIVER. 

As in fatty heart, two different forms are recognized : the fatty 
infiltration, and fatty degeneration. These forms are generally asso- 
ciated with general obesity, in which the liver appears to be one of 
the storehouses of excessive fat. In the latter the oxidation pro- 
cesses are interfered with, as in cachexia, anaemia, and phthisis ; it 
often occurs from alcoholism. 

The symptoms are not definite, and it is difficult of diagnosis. 
Jaundice is never present ; the stools may be light-colored, but even 
in the worst cases the bile is still formed. The liver may be greatly 



DISEASES OF THE DIGESTIVE SYSTEM. 553 

enlarged, reaching below the navel, but it is smooth and painless. 
Treatment. — It is well known that phosphorus, iodoform, arsenic, 
and some other drugs will cause fatty degeneration. Surely one of 
these drugs ought to cure it in its first stage, but we have no clin- 
ical reports of their use. In fatty infiltration the general treatment 
recommended for obesity should be carried out rigidly, if the disease 
is not too far advanced. 



CANCER OF THE LIYER. 

This is rarely a primary disease ; is usually secondary to cancer 
in other organs. It may arise from a blow or bruise of that organ, 
or be caused by gall-stones. There are several varieties : the mas- 
sive, involving the whole liver ; nodular, scattered throughout the 
organ ; and cancer with cirrosis. Sarcoma of the liver has been 
known to occur, but is supposed to be rare. 

The diagnosis is difficult, unless there has been cancer in other 
organs. Then if enlargement of the liver occurs, with the wasting 
and marked cachexia, it may be put down as cancerous. 

Treatment. — There are no cures on record ; conium, hydrastis, 
arsenic, and phytolacca may be tried. But the main treatment 
must be alleviative, the medicines being selected according to their 
symptoms. 

Dr. Burnett says he believes he has twice cured cancer of the 
liver with cholesterine, 3x trituration, also a "tumor of the liver." 



DISEASES OF THE PANCBEAS. 

Diseases of the pancreas have been involved in a great deal of 
obscurity. Until the time of Professor Classen, who wrote in 1842, 
nearly all our knowledge was theoretical. His observations were 
based on post-mortem appearances. He quotes earlier writers — 
Schmackffeffer, Neunian, Juppin, Casper, Baku, Morgani, and gives 
their observations. The first named examined a woman who died of 
mercurial poisoning. He describes the pancreas as " unusually 
dense, dry, and very much swollen ; it was red and inflamed through- 
out ; numerous drops of blood escaped from the cut surface. The 



554 THE PRACTICE OF MEDICINE. 

duct was very much dilated, especially at its mouth. The gland 
weighed five aud three-fourths ounces." Classen gives the symp- 
toms of acute pancreatitis as follows : " Deep-seated pain near the 
stomach, producing a peculiar anxiety, restlessness, frequent faint- 
ing. The pains bear no definite relation to the vomiting or other 
symptoms, and were not increased in proportion by external pres- 
sure. The vomiting is forcible, more or less greenish material being 
expelled. The abdomen is moderately tense, there is slight fever, and 
the appetite is but little disturbed. There is moist tongue, thirst, and 
constipation." But these symptoms may occur in many other diseases. 
The best papers on Diseases of the Pancreas are those by Pro- 
fessor Fitz in the New York " Medical Record," 1889, and a paper 
prepared for the Pennsylvania State Homeopathic Medical Society 
in 1880, by a committee composed of Drs. J. C. Morgan, A. R. 
Thomas, A. Korndoffer, and E. A. Farrington, and republished in 
Arndt's " System of Practice." 



ACUTE PANCREATITIS. 

This may run its course, and resolution take place, without being 
recognized by the physician, who supposes he is treating a gastritis 
or gall-stones. 

Severer cases are called " acute hemorrhagic pancreatitis," and 
are described as follows by Osier : " The symptoms of this condition 
are remarkable. The attacks set in with violent pain in the abdo- 
men, usually in the upper zone, but in some instances it is general. 
Nausea and vomiting are present and usually constipation. Tym- 
panitic distension of the abdomen is of frequent occurrence. Fever 
may be present, but it is an inconstant symptom. There may be 
early delirium. Collapse symptoms supervene, and death occurs 
usually from the second to the fourth day, or even earlier. The 
swelling and infiltration in the region of the pancreas necessarily 
involve the coeliac plexus, and the stretching of the nerves may 
account for the agonizing pain and the sudden collapse. In a case 
which I have reported the semilunar ganglia were swollen, the nerve- 
cells indistinct, and there was an interstitial infilitration of round 
cells. The pacinian corpuscles in the neighborhood of the pancreas 
were enormously swollen and cedematous." 



DISEASES OF THE DIGESTIVE SYSTEM. 555 

In such cases a diagnosis of obstruction, or acute perforative per- 
itonitis, is usually made. In one case in which a correct diagnosis 
was made by Fitz the patient was suddenly seized with severe pain 
in the epigastrium followed by vomiting and prostration. The abdo- 
men was distended, temperature slightly elevated, and the bowels 
were constipated. Laporotomy revealed no obstruction, but an acute 
hemorrhagic pancreatitis. Osier relates a similar case of a patient 
in the Johns Hopkins Hospital. No obstruction was found, but the 
pancreas was swollen, indurated, and inflamed. 



SUPPURATIVE PANCREATITIS. 

In this form there may be diffuse suppuration, or the organ may be 
studded with small abscesses. Of the twenty-two cases analyzed by 
Fitz, the majority occurring in adults under forty, seventeen were 
males. The disease is usually chronic, and begins with epigastric pain, 
vomiting, and prostration. Tenderness exists in the epigastrium, or 
may at times extend to the left and be quite sharply localized over the 
position of the pancreas, but a circumscribed tumor is rare. I believe 
I recently had a case of this kind. Mr. M. had suffered for several 
months from these symptoms, and had been treated for dyspepsia. 
On examination, palpation discovered no perceptible tumor. Auscul- 
tation showed a blowing sound in the epigastric region, confined to a 
small space just below the zyphoid cartilage. At first I thought it was 
an aneurism of the descending aorta. The heart was normal. On 
examining him in the knee-elbow position, the blowing sound disap- 
peared. He could not walk or ride, or lift anything, without caus- 
ing great pain in the region of the blowing sound. The pain would 
radiate upward into the chest, shoulders, back, and downward. There 
was a sensation of deathly sinking at the pit of the stomach. No 
undigested fat was found in the stool, but there was progressive 
emaciation. No medicine (I tried muriate of barium and iodide of 
potassium) or diet seemed to improve his condition. He crossed the 
lake from Chicago to St. Joseph, and shortly after he arrived was 
attacked with symptoms like cholera morbus, and came near dying. 
Blood and pus were found in his stools, and he vomited a large quan- 
tity of fluid resembling chyle. After his recovery from this attack 
there was a general improvement in his condition. A few weeks 



556 THE PRACTICE OF MEDICINE. 

after his return an examination was made with the following results : 

The blowing sound was present, but in a much less degree, and 
was more circumscribed. His general condition is much improved- 
He is gaining weight and strength, but if he becomes fatigued he 
still has some of the old pain. I believe a large abscess in the pan- 
creas discharged into the duodenum. 

Treatment. — In acute pancreatitis, I can suggest no better rem- 
edies than mercury and iris versicolor. We know that both medi- 
cines have caused it (see Schmackffeffer's " Keport " ; Dr. Burt 
found the pancreas in a cat inflamed after poisoning by iris). Both 
drugs have in their pathogenesis nearly all the symptoms of acute 
pancreatitis. 

Jaborandi, or its alkaloid, pilocarpin, which have such an intense 
stimulating action on the salivary and other glands, ought to be excel- 
lent remedies in this disease. It would be particularly indicated in 
the metasatic variety caused by suppression of mumps or an arrest 
of mercurial or other salivation. Enough in such cases should be 
given to restore the flow of saliva. 

Muriate of barium has many of the symptoms of chronic pancre- 
atitis. A case is reported in " Frank's Magazine," quoted by Mor- 
gan, cured by this remedy. The details are as follows : " A young 
man, about thirty years old, has been subject for a long time, sev- 
eral times a day, and also in the night, to such violent attacks of dis- 
tress and suffocative spells that he was obliged to roll about on the 
floor, after the fashion of an epileptic, save that he retained conscious- 
ness. He was compelled to sit absolutely straight, his head bent 
forward, a constant stream of saliva running out of his mouth. This 
flow of mucus occurred with even slight paroxysms ; it seemed most 
like saliva, of which a soup-plateful would run from the mouth. In 
the left side, a trifle below the stomach, a hard substance could be 
detected, and the patient affirmed that he has always been conscious 
that his paroxysms came from that spot. After attempting in vain 
to secure relief by a large number of remedies, he was given baryta 
muriatica pura and he was cured in two months, having used three 
drachms ; the hardness, the flow of mucus or saliva, and the tight- 
ness across the chest had all disappeared." (In this case pilocarpine 
was indicated.) 

" Symptoms recorded by pro vers show general constitutional and 



DISEASES OF THE DIGESTIVE SYSTEM. 557 

gastric disturbances which point to muriate of barium, a remedy 
which, in the earlier stages of pancreatic affection, might prove use- 
ful. There is a swelling of the salivary glands ; profuse salivation ; 
bad taste in the mouth, even the food tasting badly ; coated tongue ; 
loss of appetite ; nausea ; incessant, tormenting, ineffectual retch- 
ing ; inclination to vomiting ; violent vomiting of slimy, watery 
fluid ; vomiting of small portions of a nauseous looking and tasting 
substance for six hours ; troubles with the stomach ; pressure in the 
stomach ; continual pain in the abdomen ; diarrhoea ; profuse diar- 
rhoea, without pain in the bowels ; liquid stool : stool coated with 
mucus." 

Iodine is highly praised by Rademacher, Reid, and Richard 
Hughes. Rademacher gave a tablespoonful of a solution of thirty 
drops of iodine in eight ounces of water, repeating the dose every 
hour, and saw a rapid curative action from the drug. 

Reid used a solution of six drops in six ounces of water, and gave 
a tablespoonful (he does not say how often, presumably every few 
hours). He relates the following case cured in two weeks by this 
medicine : " An inn-keeper, aged forty years, complained of con- 
stant pressure on the stomach, with frequent empty eructations, at 
times vomiting of small amounts of tenacious, rancid mucus, without 
a real pyrosis, some constipation, and copious flow of saliva. He had 
to sit constantly. The parotid gland was healthy, the tongue moist, 
without coating, and he had much thirst. The smallest amount of 
food would satisfy his hunger, causing no gastric pain. Urine scanty, 
rather brown. Countenance somewhat pale. Mental depression and 
irritability. He attributes his condition to a cold taken some six 
months ago. There is sensitiveness to pressure in the epigastric 
region toward the navel, and at a spot on the spine corresponding to 
this. By putting the patient on his back, with his legs drawn close 
up, securing the greatest possible relaxation of the abdominal mus- 
cles, I could discover a rather oblong, transversely-lying swelling. 
Considerable abdominal pulsation ; neither stomach, liver, nor spleen 
at all sensitive ; a chronic inflammation of the pancreas was clearly 
diagnosticated." 

Hughes reports the following case cured by iodine : " A gentle- 
man had an illness that commenced in the middle of the previous 
August, with black stool and pain in the abdomen. The latter con- 



558 THE PRACTICE OF MEDICINE. 

tinued to distress him, shifting from front to back, and also to the 
right side ; he could not lie on the right side, but could always do so 
on the left. He rapidly lost flesh and strength, and toward the end 
of September came to England. The patient was sixty years of 
age, tall, of grayish complexion, and emaciated to a degree. He 
complained of a severe pain coming on one or two hours after each 
meal, and lasting during the remainder of digestion. There was no 
vomiting, but frequent nausea, accompanied by a free flow of saliva. 
Pulse was slow, large, and empty. 

Examination of the abdomen showed tenderness over the pan- 
creas, and on deep palpation, the gland could be felt enlarged and indu- 
rated. A diagnosis of pancreatic disease was accordingly made ; this 
would account for the pain and wasting. It was thought that dis- 
ease was probably malignant, though it was stated that it might be 
a simple chronic inflammation. Iodine 3x, three drops night and 
morning was prescribed ; to relieve the pain two or three drop doses 
of atropinum sulphur icum of the same potency were interposed. 
These remedies were taken regularly until December 20th, when the 
patient was so much improved that Dr. Hughes allowed him to return 
to India. The patient's stools had been carefully examined by a 
microscopist, who found fat globules and shreds of membrane in 
them." Dr. Hughes uses sulphate of atropine as a palliative for 
the pain. In my case I found codeine lx to give the promptest 
relief. 

Belladonna and atropine are recommended by the late Dr. Baehr 
in " Catarrh of the Pancreatic Duct." If Baehr had not been such 
a wonderful diagnostician, his diagnosis might be doubted. He 
reports a severe case which certainly was some form of pancreatitis, 
cured by sulphate of atropine 3x. 

Farrington recommends phosphorus when there is fatty degener- 
ation of the pancreas, but we have no clinical testimony in its favor. 

The best summing up of our present knowledge of diseases of 
the pancreas is made by Dr. Shrady in the " Medical Record " 
(editorial) March, 1890, as follows : " Considerable interest has 
been excited in the subject of diseases and injuries of the pancreas 
by the contributions of Senn and Fitz in this country, and by those 
of Lancereaux, Minkowski, and Yon Mering and others in Europe. 
The pancreas is an organ which is rarely subject to organic disease^ 



DISEASES OF THE DIGESTIVE SYSTEM. 559 

or to injury ; nevertheless, it is not entirely free from ills, and it is. 
likely that minor and functional disorders are not so very rare. In 
a recent review of this subject by M. F. de Grandmaison (" Gazette 
des Hopitaux," January 4, 1890), the following diseases are said to 
affect the pancreas : Acute and chronic pancreatitis, abscess, lithiasis, 
apoplexies, and tumors, including cysts. To this may be added lip- 
omatosis, degenerative atrophies, disorders secondary to compression, 
and functional affections. 

" Of these somewhat numerous affections, it is only chronic pan- 
creatitis, lithiasis, tumors, and perhaps functional or secondary dis- 
orders from compression that can be at present recognized. All the 
acute disorders, except, perhaps, abscess, are practically unrecogniz- 
able. The cardinal symptoms of pancreatic disease are stearrhoea, 
glycosuria, phenomena of compression, and rapid emaciation. The 
stearrhoea was first noted as a symptom of impaired function of 
the pancreas by CI. Bernard, who produced it by experiments on 
animals. It has also been noted clinically by Kuntzman, Bright, 
Unckel, Ancelet, and others. 

" Sometimes there is associated with it fatty vomiting. The fatty 
stools persist even when fat has been withdrawn from the food. 
However, stearrhoea may be absent in severe pancreatic disease, and 
it is not by any means a pathognomonic sign. 

" Glycosuria has been produced experimentally in animals by 
destruction or injury of the pancreas, and according to Lancereaux 
and his pupil, Lapierre, it may be an evidence of pancreatic disease. 
M. Lancereaux, indeed, asserts that there are three forms of diabetes, 
viz.: (1) The nervous, (2) that occurring in the obese, and (3) the 
emaciative form, the latter being due to chronic pancreatitis or pan- 
creatic lithiasis. The nervous form of diabetes results from emo- 
tional shocks, traumatism, combined with lithsemic states, and it is 
usually temporary. It is, in fact, a glycosuria of symptomatic char- 
acter only. The diabetes of the obese is the more common form ; 
it comes on slowly and progresses slowly. The diabetes with ema- 
ciation comes on suddenly; the patient rapidly loses weight ; the 
amount of sugar in the urine is large (fifty to eighty-five grammes 
daily), and the duration of the disease is not long, the patient dying 
usually of tuberculosis. The skin is rough and dry, but the boils 
and carbuncles which occur in the diabetes of the fat are not observed 



560 THE PRACTICE OF MEDICINE. 

here. The symptoms of pancreatic disease due to compression are 
chiefly those resulting from compression of the bile-duct. The gall- 
bladder is distended, the liver remaining of normal size, and icterus 
gradually develops. The general symptoms in organic pancreatic 
disease are those of cachexia and great emaciation. Often there is 
epigastric pain and intestinal dyspepsia with much flatulence and 
loose stools. 

" As for the special significance of the above symptoms we are 
still much in the dark. Stearrhcea, we are told, is rare in pancreatic 
lithiasis, but more common in primary cancer of the head of the 
pancreas. 

" Diabetes with rapid emaciation, if indicative of any pancreatic 
disease, points rather to lithiasis and secondary pancreatic inflamma- 
tion to degeneration." 

DISEASES OF THE SPLEEN. 

CONGESTION. 

Causation. — " Congestion of the spleen is of common occurrence 
under a large number of circumstances. It habitually takes place 
during the progress of digestion. Pathologically it is mainly observed : 
(1) In dependence on lesions involving mechanical impediment to the 
escape of blood from the spleen, such as obstructive cardiac and pul- 
monary affections, and especially those diseases of the liver, such as 
cirrosis, in which the portal vessels are implicated ; and (2) in con- 
nection with numerous acute febrile disorders, of which typhus and 
enteric fever, pyaemia, and malarious affections may be taken as the 
types. 

Morbid Anatomy. — " In congestion the blood accumulates in the 
small vessels and intervascular blood-passages, and the organ becomes 
proportionately enlarged. The rapidity with which this enlargement 
takes place and subsides is remarkable. The congested organ may 
attain five or six times its original bulk, while retaining its normal 
form ; and usually becomes, in proportion to the amount of blood 
which it contains, pulpy, lacerable, and even diffluent. When the 
congestion is frequently repeated, as in ague, or long-continued, as 
in portal obstruction, the enlargement tends not only to increase, but 
to become permanent." 



DISEASES OF THE SPLEEX. 561 

Symptoms and Progress. — " Simple congestion of the spleen 
rarely, if ever, reveals itself by symptoms, and equally rarely calls 
for special medical treatment. It can, however, often be recognized, 
during life (if sought for in those cases in which it is liable to 
occur), by the presence of a manifest tumor in the splenic region. 
The normal spleen is situated upon the cardiac extremity of the stom- 
ach, its convex surface being in contact with the diaphragm, and no 
part descending below the ribs. Its lowest point is then in close 
proximity with the anterior extremity of the eleventh rib, from which 
point upwards a limited area of dulness, due to its presence, may 
sometimes be detected on the left side of the thorax. The enlarged 
organ, however, while partly risiog into the chest and increasing the 
area of splenic dulness in that situation, mainly spreads farther and 
farther into the abdominal cavity, taking a course downward, forward, 
and inward. In cases of extreme enlargement it may occupy nearly 
the whole of the left half of the abdomen, extending from the ribs 
above to the groin below, from the lumbar region behind to beyond 
the umbilicus, and causing distinct protrusion of the abdominal par- 
ietes. A splenic tumor is usually readily movable, sinking and ris- 
ing with the respiratory movements, and capable of obvious displace- 
ment under manual pressure ; its sharp anterior edge can generally 
be readily felt, and found to present the characteristic s})lenic notch. 
If symptoms be present they are mainly a sense of weight or tension 
in the side and tenderness on pressure/' 

" Occasionally rupture of the greatly congested spleen takes place ; 
in which case death occurs with some rapidity, either from the escape 
of blood into the peritoneal cavity, or from peritonitis."' (Bristowe.) 

Treatment of Hypercemia. — Acute congestion is best treated by 
aconite lx, veratrum viride lx, or tincture and phosphate of iron 6x. 
The special indications need not be given, as they are well known. 
If it is attended by intense pain of a throbbing, aching character, 
phenacetin, five to ten grains of the 6x, repeated every half-hour, 
will soon give relief. Acetanelid in similar doses may be equally 
effectual. 

Arnica, internally, is the specific if the cause has been traumatic, 
as from a blow or bruise. In such cases it should be applied exter- 
nally. It is also useful if the congestion occurs during fevers or 
from abuse of quinine. Bellis has been used by Dr. Burnett in such 

36 



562 THE PRACTICE OF MEDICINE. 

cases. Bryonia will be useful if the patient suffers from severe stitch- 
ing pains, which are aggravated by the slightest motion. Cinchona 
and quinine, which are so prone to cause hyperaemia, ought to be spe- 
cific in some cases. In some cases of anaemia, sudden attacks of 
hyperaemia of the spleen may occur and lead to hemorrhage. In 
such cases ergot given in doses of ten to twenty drops every two 
hours will arrest it, but it should be followed by phosphate of iron 
6x, ten grains after each meal. If due to sudden arrest of the men- 
strual flow, sabina, sanguinaria, and senecin are the appropriate 
remedies. If it attends stasis in the portal system, mercurius dul- 
cis, two grains every two hours until ten grains are given ; this 
should be followed by laxative doses of Carlsbad salts, Epsom salts, 
or Rubinat water. This medication will soon remove the hyper- 
aemia. 

If the congestion occur during repeated paroxysms of ague, qui- 
nine, arsenic, cedron, or muriate of sodium should be given, and the 
paroxysms arrested as soon as possible. If the congestion remains, 
arnica, or ceanothus will remove it. 

Ceanothus is doubtless a specific spleen remedy. How it gained 
such a reputation is as much a mystery as the original discovery of 
the anti-malarial virtues of cinchona bark. Ceanothus, under the 
name of " Jersey tea," was extensively used as a beverage and sub- 
stitute for tea during the Revolution, and is still so used by the poor 
who live on the Atlantic coast from New York to North Carolina. 
This region is intensely malarious. Probably it was observed that 
those who largely used this beverage got rid of splenic pain and 
enlargement. I can imagine no other way of its discovery as a 
splenic remedy. It is said that the discovery of the value of Peru- 
vian bark was accidentally made by the Peruvians, who drank the 
water of streams impregnated to bitterness by the leaves and branches 
of the cinchona. 

Dr. Burnett, in his admirable little monograph on " Diseases of 
the Spleen," has proved the specific value of ceanothus in many 
disorders of that organ. I first found a notice of its usefulness in 
an old work on " Botanic Practice," published in 1820, and repro- 
duced it in the first edition of " New Remedies." Dr. Dunham veri- 
fied its value. The dose varies from the 6x to thirty or sixty drops 
of the tincture. 






DISEASES OF THE SPLEEN. 563 

INFLAMMATION. 

Causation. — " Inflammation of the spleen, at least in acute 
form, is exceedingly rare, excepting in cases due to injury, embolism 
pyaemia, or the presence of morbid growths or foreign bodies. 

Morbid Anatomy. — " Splenic embolism is most frequently a con- 
sequence of valvular disease of the heart. It leads to the formation 
of wedge-shaped blocks, or masses, which, varying in size from a 
cubic inch or two downwards, are multiple, and usually near the sur- 
face of the organ. In the first instance they are mainly hemorrhagic, 
and distinguishable from the splenic tissue by their darker color and 
greater solidity ; but soon the coloring matter gets absorbed, and the 
masses pass through various stages of reddish brown, yellowish brown, 
and buff color, until they become almost pure white. Sometimes they 
soften into a puriform pulp, sometimes undergo suppuration, and some- 
times (especially if small) get absorbed, leaving depressed cicatrices 
behind in which earthy particles may remain imbedded. The pres- 
ence of these infarctions generally gives rise to inflammation in the 
peritoneal surface over them. Pyaemic formations present much the 
same characters ; but they are usually more numerous and smaller, 
and their tendency to soften, suppurate, and involve the peritoneum 
covering them, is much more marked. Splenic abscesses may result 
from the above and various other causes, and, like other abdominal 
abscesses, may acquire large dimensions, and are liable to various 
terminations. They may open externally through the abdominal 
walls, or rupture into the peritoneum, or discharge their contents 
into the colon, left lung, or pleura. Adhesive inflammation is not 
uncommon at the surface of the spleen, and occasionally circum- 
scribed suppuration occurs between this organ and some neighboring 
part, such as the stomach, diaphragm, colon, or abdominal walls. 

Symptoms. — " In most of the affections now under consideration 
there is little or nothing special excepting locality to direct attention 
during life to the spleen as the seat of the disease. There may be, 
and indeed probably always is, manifest increase of size of the organ, 
together with uneasiness, pain, and tenderness. The pain, when 
severe, is mainly due to circumscribed peritonitis, and, from the posi- 
tion and relations of the organ is liable to augmentation during the 
respiratory movements. The recognition of an abcess will depend 



564 THE PRACTICE OF MEDICINE, 

on its attainment of such a size as to form an appreciable fluctuating 
tumor in the splenic region, and on the phenomena that attend and 
follow the process of pointing and the discharge of its contents. In 
all these cases, sympathetic vomiting and febrile symptoms will 
almost certainly manifest themselves, and rigors are not unlikely 
to supervene. But it is rare for the splenic affection to be so free 
from complication as to justify us in attributing them to it. 

" Special treatment will only be called for when pain is complained 
of or when an abscess becomes manifest. In the former case, poul- 
tices and fomentations are the most useful applications ; in the lat- 
ter the case must be treated as one of hepatic or other internal 
abscess." (Bristowe.) 

Acute Splenitis is not a common disease in temperate climates. 
In this respect it resembles acute suppurative hepatitis. The most 
common cause, according to Virchow and Billroth, is " hemorrhagic 
infarctions occurring during infectious diseases." They may occur 
during endocarditis, pyaemia, or when the blood is seriously altered 
by poisonous secretions. The emboli plugging the splenic blood- 
vessels develop septic properties. The indications are : (1) To 
improve the condition of the blood ; (2) to remedy the consequences 
of the infarction. 

Aconite and veratrum viride are of value so far as they are capa- 
ble of reducing the force of the circulation. Arnica, bellis, eucalyp- 
tus, arsenic, and carbo. vegetabilis are indicated for the swelling and 
plugging in inflammation from the rupture of blood-vessels. 

Bryonia is recommended by Dr. E. Hughes when the capsule of 
the spleen is inflamed. Ranunculus is recommended by Bcenning- 
hausen and Dunham. My experience has been limited in this dis- 
ease, but it is my conviction that the best remedies for chronic 
splenitis will prove to be cinchona and eucalyptus, given in small but 
appreciable doses. If the symptoms point to a profound deteriora- 
tion of the blood, the above remedies should be aided by arsenic or 
the arsenite of iron. 

When the spleen becomes enormously enlarged, uvedalia inter- 
nally, in doses of ten to thirty drops four times a day, should be 
given, and a thirty per cent ointment of the same drug rubbed in, 
morning and night. I treated two cases with this medicine and was 
pleased with the improvement which followed its use. 



DISEASES GF THE SPLEEN. 565 

Iodine and iodide of potassium are recommended by the old 
school, but there is no positive proof of their value. 

Ergot, given by deep injections into the substance of the spleen, 
is recommended by Hammond, but the results are not uniformly 
good. Mosler used a two per cent solution of carbolic acid and 
Fowler's solution of arsenic (one part to ten of distilled water), 
especially in leucemic spleen, but some of his cases resulted disas- 
trously. 

Carduus, chelidonium, and muriate of sodium have in Dr. Bur- 
nett's hands proved useful when it was coincident with enlargement 
of the liver and stasis in the portal system. In suppurative splen- 
itis, if diagnosed in time, we may prevent extensive suppuration by 
the use of silica, hepar sulphur, or hypophosphite of lime. 



SPLEXALGIA. 

This malady is described by Wardell in Eeynold's " System of 
Medicine." It is defined as consisting of attacks of pain in the 
region of the spleen induced by violent exercise, such as running, 
riding on horseback, rapid walking, and climbing hills or stairways. 
It is doubtful if the pain is in the spleen. It is most probably a 
myalgia, as described by Anstie. 

Sympto'ms. — TThen attacked, the individual halts, places his 
hand on the left hypochondrium, and bends over to that side. Hard 
pressure in the region of the spleen seems to relieve the pain. It 
is greatly aggravated by the deep inspirations which are made under 
the circumstances. The inspirations are cut short by a " stitch " 
or " catch " which causes such pain that the sufferer cries out. It 
is somewhat like the pain in pleurisy. The intensity of the pain is 
soon over, but in rare cases it has been known to last for hours. 
A sore sensation may be felt for several days after prolonged 
attacks. There is a popular belief, or superstition, that if the spleen 
is removed the individual is rendered insensible to fatigue under 
the most violent exercise. 

I do not think this affection should be called a splenalgia any more 
than myalgia of the intercostal muscles should be called a pleurodynia. 
The attachments of the muscles, especially their upper attachments, 
are the seat of the pain. When a youth I was a great sufferer from 



566 THE PRACTICE OF MEDICINE. 

these attacks. They have continued whenever I have indulged in 
unwonted exercise. I could not play base-ball, run races, or ride a 
trotting horse, without being liable to such severe attacks as to 
oblige me to lie down i£ running, or to get off my horse if riding. 
No exertion of will power ever enabled me to endure the pain and 
keep in motion. In my case the pain generally commenced on the 
left side at the border of the last true rib, and if I did not immedi- 
ately bend to that side, and press hard upon it, or lie down on my 
left side with my body bent, it would spread all over the left flank 
and across the abdomen. What convinced me that the pain was not 
splenic was that occasionally the pain commenced on the right side, 
and extended to the left flank. This right-sided pain has been 
erroneously described as hepatalgia. When a student of medicine 
I tried all the apparently indicated drugs, in view of effecting a 
cure, but without avail. I believe it depends on the same causes as 
any other myalgia, namely, a loss of tone in the muscular system. 
Anaemia or a constitutional delicacy is the etiology. 

Treatment, — No drug acts quickly enough to relieve the suffer- 
ing unless it is amyl nitrite or chloroform. I have never tried them, 
but should not hesitate to do so. To cure the tendency, I would 
advise the use of iron and hypophosphate of sodium or potassium, 
in cases of anaemia. If the patient is neurotic, ignatia, strychnine, 
arnica, and cimicifuga. Hydrastin lx trituration continued three 
times a day for weeks ought to effect a cure. 



HYPERTROPHY OF THE SPLEEN. 

Causation. — " True hypertrophy is for the most part the conse- 
quence of long continued or repeated congestion. It is therefore fre- 
quently associated with cirrosis and other chronic affections of the 
liver, and is a common consequence of repeated attacks of malarial 
fever. It is, moreover, a usual complication of rickets. But some 
of the most remarkable examples of this affection are furnished by 
persons who have never suffered from any of the above disorders, 
and in whom there is no history pointing to the operation of any spe- 
cific cause." 

Morbid Anatomy. — "In true hypertrophy, the organ enlarges 
without undergoing any obvious change in texture ; there is a gen- 



DISEASES OF THE SPLEEN. 567 

eral increase of all its elements in pretty nearly equal proportion ; 
and it requires a more or less firm fleshy consistence. It is in this 
condition, and in that associated with leucocythaemia, that the spleen 
attains its greatest volume, sometimes filling the left side of the 
abdomen from the ribs above to the pelvis below, and from the lum- 
bar region behind to some inch or two, or more, beyond the umbil- 
icus. It may then measure as much as sixteen inches in length, ten 
in breadth, and five or six in thickness, and weigh ten, twelve, or 
even twenty pounds. It retains its normal shape. 

Symptoms and Progress. — " The symptoms due to simple hyper- 
trophy are vague and difficult to disentangle from those of other 
lesions with which they are frequently associated. Persons thus 
affected often suffer from anaemia, discharges of blood (especially 
from the gastro-intestinal mucous membrane), and abdominal dropsy ; 
but it is uncertain how far these phenomena depend on the hepatic 
lesion which so commonly goes along with splenic enlargement, how 
far on the splenic disease. But, putting such symptoms aside, there 
is nothing left to indicate the presence of splenic hypertrophy beyond 
the local phenomena to which it gives rise. The chief of these is 
the manifest existence of a tumor which presents the characters 
(before described) of enlarged spleen, tough and unyielding in con- 
sistence, giving to the patient a sense of weight and fulness, espe- 
cially if he lies upon his right side, and unattended with pain or ten- 
derness on pressure. A venous hum, of musical character, may 
occasionally be recognized on the application of the stethoscope over 
the tumor. The duration of these cases is always uncertain, and 
often much prolonged. In some instances amelioration or cure takes 
place under suitable treatment ; in some the organ remains station- 
ary, and yet with little manifest deterioration of the patient's health ; 
in many death ensues sooner or later, either from simple anaemia and 
debility, or from these conditions associated with hemorrhage, dropsy, 
or some intercurrent affection." (Bristowe.) 

The treatment of hypertrophy must depend largely on the consti- 
tutional malady which has given rise to it. If it be a sequel of ague, 
arnica or arsenic is indicated ; if the patient be suffering from rickets, 
the remedies suitable for that condition must be employed ; if there 
be heart, pulmonary, or renal disease, our efforts must be regulated 
accordingly. In many cases no such clue is furnished ; and we must 



568 THE PRACTICE OF MEDICINE. 

then have recourse to those remedies which the general condition 
of the patient seems to suggest ; among the more important may be 
enumerated iodine, iodide, and bromide of potassium, iron, cinchona, 
ceanothus, etc. The bowels should be kept freely open by the use 
of mild laxatives, if necessary. 

Dr. Burnett, in his " Diseases of the Spleen," gives some very 
interesting cures of enlarged spleen made by means of chelidonium, 
carduus, etc., when the liver was also enlarged. I have written of 
the value of ceanothus in another place. 

Ichthiol internally, two to four grains daily, and externally in the 
form of an ointment, ten to twenty per cent, is highly recommended 
in Germany for hypertrophy of the spleen. It acts better than 
iodine, and is quite safe. 

Grindelia squarrosa has lately been used successfully in hyper- 
trophy of the spleen in consequence of malarial fevers. In the 
" Pharmacology of the Newer Remedies," pages 755 to 761, are given 
twelve cases of this disease cured by this drug. Thirteen physicians 
report favorable results from its use. The chief symptoms were 
great enlargement of the spleen, with much tenderness on pressure, 
paroxysms of ague that had resisted quinine, ascites, anaemia, and 
leucocythemia. The doses were from ten to thirty drops every three 
or six hours. The drug soon arrested the chills, the swelling and 
tenderness of the spleen gradually disappearing. 

It is asserted that its action on the liver is similar to leptandra. 
Dark-colored stools follow its use, with improvement in the symptoms 
of hepatic torpor and portal congestion. 



CHAPTER VII. 

DISEASES OF THE URINARY SYSTEM, 



DISEASES OF THE KIDNEYS. 

NEPHRALGIA. 

Definition. — In its strictest sense this term would mean pain in 
the kidneys ; in its broadest sense, pain in the region of the kidneys 
but having some connection with those organs. " There is a popular 
impression," says Keyes, " that all kidney diseases are attended by 
pain in the back, the severity of the disease regulating the amount of 
pain. This impression is incorrect. Some kidney diseases are 
attended by pains in the back, others are not." Pain over the region of 
the kidney is a symptom by no means confined to diseases of that or- 
gan. It is found in many morbid bladder and prostatic conditions ; 
is an accompaniment of hemorrhoids, uterine diseases, and very often 
is a simple lumbago, not depending on any internal disorder. In 
bladder and prostatic diseases the pain in the back is more likely to 
occupy the sacral region, particularly the sacral-iliac synchondrosis 
of one or both sides. The same pain occurs from piles. Uterine 
pains may locate in any portion of the spine — reflexly, but if in the 
uterus itself, is in the lowest sacral region. In lumbago the pain is 
aggravated by motion of the trunk, or in rising from a sitting pos- 
ture ; is usually worse in damp weather, or on the approach of a 
storm. 

In true nephralgia the pain is in the kidneys. It is deep-seated, 
felt in the back over the kidneys, usually unilateral, often extending 
down around the side, following the course of the ureter, sometimes 
continuing into the testicle, and complicated by bladder symptoms 
suggestive of stone or chronic cystitis of the neck. The pain varies 
in intensity, and is usually made worse by fatigue. Pressure gen- 
erally aggravates, but sometimes relieves. Often the patient cannot 



570 THE PRACTICE OF MEDICINE. 

lie in bed on the affected side. The pain is usually a dull, deep ache, 
occasionally sharp, darting, pricking, or lancinating in character. 
It may appear suddenly or gradually, and remain for hours or years, 
according to the cause. Nephralgia does not mean a pure neuralgia 
of the kidneys, which is a very rare affection. The latter, however, 
may and does sometimes occur in a person who suffers from neu- 
ralgic attacks in other parts of the body. One form of neuralgia 
of the kidneys is very often caused by irregular use of the sexual 
organs, or excitement without gratification. Nephralgia may be 
caused by kidney-stone, or organic kidney diseases (cancer, tumor, 
displaced or floating kidney, or pyelitis). Excessive acidity of the 
urine is a frequent cause ; or retention of the urine. We should not 
venture on a diagnosis of nephralgia until we have eliminated all the 
above organic diseases, as well as lumbago, uterine, prostatic, or 
hemorrhoidal diseases. We should then examine the urine. If we 
find the urine excessively acid, we may safely say the nephralgia is 
due to that condition. Oxaluria is often a cause of a dull, heavy, 
wearing nephralgia. I have found this condition usually associated 
with some form of hepatic disorder. If the urine is found healthy, 
neutral, and if it becomes profuse and watery after the subsidence 
of the pain, we may safely diagnose the case as neuralgia, especially 
if the pains are sharp and paroxysmal. 

Treatment. — Nephralgia from acid urine requires bryonia, col- 
chicum, cimicif uga, salicylate of sodium, and salol, aided by the free 
use of such alkaline waters as Vichy, Carlsbad, and similar springs 
in this country. The citrates of lithium and potassium, and the ben- 
zoates of lithium and ammonia, are useful when indicated. 

In neuralgia, purely functional, aconite, belladonna, atropine 
(3x), berberis, cannabis indica, coccus cacti, phosphorus, turpen- 
tine, valerianate of zinc, and phenacetin are the most useful. 

If the neuralgia arises from ungratified sexual erethism, which 
cannot be subdued by mental diversion or physical exercise, the 
bromides, or salix niger, should be given in sufficient doses to keep 
the erethism in abeyance. 

CONGESTION OF THE KIDNEYS. 
Active congestion of these organs is not usually a condition which 
is of long continuance. It is supposed to be present in all fevers. 



DISEASES OF THE URINARY SYSTEM. 571 

Osier says " the kidney of fever is commonly swollen, the blood-ves- 
sels are congested, and the cortex frequently shows traces of cloudy 
swelling." Acute congestion is always present in the early stages of 
nephritis, whether due to cold, influenza, or severe renal irritants. 
Excessive doses of turpentine, copaiva, cantharides and all that class 
of drugs invariably cause hyperemia of the kidneys. Acute con- 
gestion is usually attended by a heavy, dull pain in the lumbar region ; 
scanty, high-colored urine, and slight fever. Chronic congestion is 
usually a mechanical hyperemia caused by chronic disease of the 
heart or lungs, and the treatment should be directed to those organs 
mainly. All renal irritants primarily cause acute, and secondarily 
chronic congestion. They must be selected according to their symp- 
toms, and the dose 3x to 6x in acute, and mother tincture to 3x in 
chronic cases. Medicines are not all that are needed in renal con- 
gestion. The diet and clothing of the patient are equally important. 
In acute congestion no red meat, beer, or alcohol in any form should be 
allowed. No rich soups, eggs, or oysters. The drink should be mainly 
pure water — that water which contains the least mineral or inor- 
ganic matter. Milk or buttermilk are next in value to water. The 
inner clothing should be wool, sufficient to keep the skin warm and 
moist. 

HEMATURIA. 

Definition. — A discharge of blood from the urinary passages. 

Causes. — It may occur during the progress of any malignant or 
infectious fever, and in scurvy, purpura, haemophilia, and leukemia. 

Renal causes are congestion and inflammation ; Bright's disease ; 
infarcation of the kidneys; stone in the kidneys, cancer, tubercles, and 
tumors; parasites in the kidneys; the filaria sanguinis hominis, and 
the bilharzia; drugs, such as turpentine, carbolic acid, cantharis, and 
other renal irritants. It is important to study these drugs and the 
way they act, for they are our chief remedies in haematuria. 

A stone in the ureter or bladder may cause considerable bleeding. 

Diseases of the bladder, such as cancer, varicoses with rupture, 
ulceration, villous tumors, and foreign substances in that viscus. 
Blood may come from the walls of the urethra during an attack of 
urethritis. 

Injuries may produce bleeding from the urinary passages. A fall 



572 THE PRACTICE OF MEDICINE. 

or blow on the back may rupture the kidney and cause very free 
bleeding. Injury to the bladder or prostate may cause it. The use 
of the catheter is often followed by hemorrhage. 

There are cases of hematuria which may exist for a long time 
without a discovery of its cause, particularly in young persons. Dr. 
Gull quaintly designated these cases as " renal epistaxis." Vicarious 
menstruation may assume this form ; two cases have occurred in my 
practice in blooming young girls. They suffered no pain in the uri- 
nary organs, but had for a day or two the discomforts which attend 
menstruation. A variety of hsematuria has been termed malarial, 
occurring from malarial poisoning. 

Diagnosis. — It may be easy to recognize blood in the urine, but 
more difficult to tell where it comes from. The urine, when it con- 
tains blood, has a peculiar " smoky " appearance, the color varying 
from a light to a deep red, or it may have a dark porter color. A 
saturated uric acid urine may sometimes be mistaken for bloody 
urine. I have seen many cases when the only sign of hsematuria 
was a soot-like sediment — black or very dark brown. Under the 
microscope this sediment was composed of broken-down blood glob- 
ules ; the black appearance is caused by its long retention in the 
bladder. Ke} r es thus defines the diagnostic points : " If the bleed- 
ing is from the fore part of the urethra some of it will reach the 
meatus between the acts of micturation ; if behind a narrow stricture, 
or posterior to the membraneous urethra, it will not. Blood effused 
into the urethra clots there, and assumes the shape of a leech, or a 
tape or thread. Such clots are apt to come out with the first gush of 
urine, although, if there be a tight stricture, they may not be able 
to squeeze through until the stream is running at full force, and con- 
sequently would not appear until the middle or near the end of the 
flow. Blood from the seminal vesicles will be clotted and mingled 
with the yellow bodies found there, and with spermatozoa. Blood 
from the prostatic sinus is pretty sure to be clotted, perhaps in strings 
and threads mingled among flakes and pus-corpuscles. When blood 
comes from this region, the spermatic fluid in sexual intercourse is 
very apt to be bloody. Blood from the neck of the bladder may or 
may not be clotted. Often a few irregular clots will come first ; 
then smoky urine will flow, and finally, as the bladder expels its 
last drops, the prostrate and vesical neck being squeezed, a little 



DISEASES OF THE URINARY SYSTEM. 573 

highly-colored urine, or fluid resembling pure blood, will be voided. 

" Blood flowing from any part of the bladder, and sometimes from 
the prostatic sinus as well, if it flows rapidly into an empty bladder, 
is pretty sure to clot in mass, and to dissolve afterward. If, how- 
ever, it flows very slowly, or into a bladder partly filled with urine, 
it may not clot at all, but remain freely suspended in the urine, 
retaining its natural red color ; or, after a few hours, become brown 
or black by the deoxidizing effect of the urine, the red oxyhemo- 
globin, becoming converted into brown methsemoglobin. Blood may 
clot in the pelvis of the kidneys, but coming down from the kidneys 
does so usually in a fluid state, either as red or black blood ; fibrin- 
ous clots may, however, pass the ureters with symptoms of kidney 
colic. Blood from the kidneys has no special physical character by 
which it can be distinguished from blood coming from the blad- 
der, except in those cases where blood-casts of the uriniferous tubules 
are found. These are pathognomonic. The quantity of blood flowing 
from a cancerous kidney varies very greatly, sometimes disappearing 
for weeks, and then recurring violently. Kayer says that, from a 
comparative examination extending over a length of time, of all urine 
passed by patients with calculous pyelitis or cancer on the kidney, 
he noticed several times Qpliisieurs fois) that the urine voided three 
hours after eating was more than ordinarily loaded with blood. 
When the blood comes from the kidneys, there is often pain or 
heaviness of the lumbar region of one or both sides. Blood may 
flow from the ureter if a calculus be retained there. Rayer has 
noted several cases, in two of which there were also exuberant gran- 
ulations in the ureters, which bled. 

" The origin of the blood in the urine may in some cases be 
cleared up by a clever expedient resorted to by Thompson for the 
differential diagnosis of pus from the bladder or kidneys in obscure 
cases. A soft catheter is gently introduced just within the bladder 
neck, the urine drawn off, and the cavity washed out very gently 
with tepid water. If the water cannot be made to flow away clean, 
the inference is that the blood comes from the cavity of the bladder. 
If it will flow away clean, then the catheter is corked for a few 
moments, the patient being at rest, and the first drachm of urine 
which collects may be drawn off and examined. The bladder is now 
again washed out, and if after a single washing the second flow of 



574 THE PRACTICE OF MEDICINE. 

injection be clear, while the drachm of urine is bloody, the infer- 
ence is again complete that the blood comes from one or the other 
kidney. Bloody urine is always albuminous." 

Treatment. — Absolute rest on the back is very necessary. The 
desire for frequent urination should be controlled if possible by the 
will. But little fluid should be drank. Dr. Keyes recommends the 
Rockbridge alum mineral water. I have found very useful, pure 
water slightly acidulated with sulphuric acid. 

Any drug which sufficiently irritates the kidneys to cause bleed- 
ing from those organs will probably cause bleeding from any portion 
of the urinary tract. We do not yet know of any drug which has 
a special affinity for any one portion of that tract. 

Hamamelis is of real value in many cases. Theoretically it is 
indicated when the cause is varicosis with rupture of the veins, but 
we have no means of knowing whether blood comes from the veins 
or the arteries, because the urine changes the color of the blood. If 
the patient has piles or portal congestion, and general varicosis, we 
may suspect venous hemorrhage. Carduus, collinsonia, sesculus, 
aloe, and sulphur may be indicated along with hamamelis. If there 
is a good deal of irritation of the urinary passages, and the blood is 
bright red and passed frequently, turpentine, erigeron, erechthites, 
oil of sandal-wood, cantharides, cannabis, millefoil, cubebs, and 
copaiva. In such cases the remedy should be given in minute doses, 
not lower than the 2x. If, on the contrary, the blood is scanty, form- 
ing a sooty sediment, and the hemorrhage appears to be passive, 
they may be given in the lx dilution or even a few drops of the 
tincture. Other remedies for passive hematuria are ergot, trillium, 
gallic acid, rhus aromatica, phosphorus, lycopus, digitalis, thapsi 
bursa pastoris, hydrastis, chimaphila, uva ursi, mitchella, epigaea, 
corn silk, ustilago, pulsatilla (especially in vicarious hematuria), 
pichi, galium, arsenic, creosote, carbolic acid, senecio, and many 
others. 

Each medicine must be selected according to the totality of the 
symptoms, of which the chief must be hematuria. I doubt the uni- 
versal value of arnica when traumatism is the cause. Turpentine 
or any other renal irritant is just as likely to be the remedy. 

When the bladder has become filled with a solid clot, Keyes says : 
" Let it alone ; no harm can come of it. It will dissolve and come 






DISEASES OF THE URINARY SYSTEM. 575 

away ; any attempt to pump it out through a catheter or break it up 
or dissolve it, if successful, will only allow the blood to re-collect, and 
is fraught with danger (to the patient) of exciting inflammation by 
violence. The best treatment is opium to control desire to urinate, 
rest, and diluents." 

Pepsin (papoid would be better) has been injected, with the 
result that a digested blood has escaped readily through the cathe- 
ter. Peroxide of hydrogen is said to dissolve blood-clots readily. 

Phosphate of iron, 3x to 6x, has been recommended when the 
bleeding was active and from the kidneys, with much arterial excite- 
ment. I have never tried it. In a few cases of haematuria during 
anaemia, the tincture of the muriate of iron has seemed to be of ben- 
efit. Dr. Gross (" Practice ") praises it highly in doses of twenty 
drops three times a day. 

Piperazin, in doses of five to ten grains three times a day, has 
cured many obstinate cases of renal haematuria. The lower tritura- 
tions might be equally effectual. 



HEMOGLOBINURIA. 

Definition. — A condition characterized by the presence of blood 
pigment in the urine. " The blood cells," says Osier, " are either ab- 
sent or in insignificant numbers. The coloring matter is not haematin, 
nor in reality always haemaglobulin, but it is most frequently met- 
haemoglobin." The urine has a red or brownish red, sometimes quite 
black, and usually deposits a heavy brownish sediment. When the 
haemaglobin occurs only in small quantities it may give a lake or 
smoky color to the urine. The urine is generally albuminous. It 
may be red, when the number of blood cells are small. Two kinds of 
haemaglobinuria are recognized — the toxic and the paroxysmal. 

The toxic is usually caused by the poison of scarlet fever, yellow 
fever, typhoid fever, and syphilis. It has followed severe burns. It 
may occur after very violent exertion. It sometimes occurs in horses, 
coming on with great suddenness and associated with paresis of the 
hind legs, death occurring in a few hours or days. It has been caused 
in men by the administration of chlorate of potassium, pyrogallic 
acid, arseniuretted hydrogen, carbon dioxide, naphthol, and muscarin. 

Paroxysmal haemaglobinuria is a rare and mysterious disease. It 



576 THE PRACTICE OF MEDICINE. 

occurs in occasional attacks of passage of bloody urine in which the 
coloring only is present. It appears to be caused by cold and exer- 
tion, and has been brought on by the cold foot-bath. It is believed 
to be associated with Kaynaud's disease. It sometimes attends mala- 
ria and jaundice. 

Osier says the essential pathology of the disease is unknown. He 
seems to imply that it is a vaso-motor neurosis. 

Treatment. — The old-school treatment of this disease is unsatis- 
factory. " Nothing seems to check the occurrence of the attacks." 
If chlorate of potassium and the other drugs above mentioned cause 
this disease, it would seem that they ought — according to the law 
of similia — to cure it. 

It is a fact, however, that a disorder of the human body, or its 
fluids, produced chemically, is not cured by the drugs capable of 
producing it. At least, this has been my experience. I would not 
be understood as denying their ability to cure. Our literature is 
absolutely sterile of any reports of cures of haemaglobinuria, and I 
have never treated a case. 



NEPHROLITHIASIS— (Renal Calculus). 

Definition. — The deposit in the pelvis of the kidney, or in the 
substance of the kidney, of concretions formed from the solid con- 
stituents of the urine. 

Etiology. — In the kidney substance itself, a separation of the 
urinary salts may occur. These deposits do not need further men- 
tion, as they do not cause appreciable symptoms. 

In the pelvis and calyces of the kidneys concretions occur of 
various sizes and appearances. 

(1) Renal sand ; small gritty particles like brick-dust. They 
may be voided in the urine for long periods without causing any 
symptoms, except in children, whose ureters and urethras are so 
small as to be irritated by the sand. 

(2) Larger concretions from the size of a squirrel-shot to a bean ; 
they may be either single or multiple, round or smooth, irregular or 
covered with sharp projections. It is the smaller of these which pro- 
duce renal colic. 

(3) There are other forms, like the " coral " or " dentritic " cal- 



DISEASES OF THE URINARY SYSTEM. 577 

culi, which may block up the orifice of the ureter, or fill the pelvis of 
the kidney like a mould. 

Chemistry. — (1) Uric acid calculi are the most common and 
the most important. They form the renal sand, the small, solitary, 
multiple, and dentritic. They are hard, red, and generally smooth ; 
stratified and very dense. Urates and uric acid may be mixed in 
the stone. 

(2) Oxalate of lime ; which form mulberry-shaped stones studded 
with sharp points and spines. They are very hard, dark in color, and 
are composed of oxalate of lime and uric acid. 

(3) Phosphatic ; composed of ammonio-magnesium and phos- 
phate of lime with occasionally the carbonate. They are not often 
met with. 

(4) Cystine, xanthine, carbonate of lime, indigo, and urostealith 
are rare forms of calculi. 

Symptoms. — Eenal calculi may produce definite and character- 
istic symptoms, as pain in the back, which may be only a dull sore- 
ness or aching in the lumbar region, or it may be severe and appear 
in paroxysms. It is generally on one side, that of the affected kid- 
ney, but may be confined to the sound kidney. Pain of a similar 
nature may occur in movable kidney. We should be cautious about 
our diagnosis from pain alone, for a sound kidney has been cut down 
upon in the effort to find the stone. Hematuria is a prominent 
symptom. It usually occurs after exercise, riding or walking, or 
lifting. It is seldom profuse, but may persist a long time if the 
patient cannot remain at rest. Sometimes the only sign of bleeding 
is a smoky-hue of the urine, as after scarlatina. Pyelitis and pyeuria 
often occur from the constant iritation of the stone. 

When the calculi enter the ureter we have a renal colic. The 
attacks may come on suddenly, without apparent cause, or after lift- 
ing, horseback riding, jumping, or a fall. It is an agonizing pain 
which is nearly always confined to one side, starting in the flank ; it 
then passes down the groin, following the course of the ureter, and 
is often felt in the testicle, or down the inner side of the thigh. It 
has been known to radiate to different and remote parts, as the 
stomach, chest, and dorsal region. In severe attacks there is violent 
retching and vomiting during the pain, and the patient is cold and 
almost in collapse, with cold perspiration and feeble pulse. There 

37 



578 THE PRACTICE OF MEDICINE. 

is probably no suffering so intense, not even childbirth or angina 
pectoris. 

The attacks may last for an hour, or for several days, with inter- 
vals of temporary relief. Intense dysuria is present, with almost 
constant desire to urinate. The urine is generally scanty and bloody, 
but I have seen instances when it was very profuse and watery, prob- 
ably coming from the sound kidney. The urine may be entirely 
suppressed even when one kidney is sound, but it generally occurs 
when the other kidney is seriously diseased, or when only one kid- 
ney exists. In such cases uraemia, sometimes fatal, occurs. 

Diagnosis. — The pain in floating kidney may be mistaken for 
the pain of stone in the pelvis of the kidney. Renal colic may be 
mistaken for intestinal colic, or colic from biliary calculi, unless the 
symptoms are carefully located. Some of the pains of dysmenor- 
rhea, also crural and inguinal neuralgia, simulate renal colic. But 
the distinctive features of renal colic are the situation and direction 
of the pain, the retraction and tenderness of the testicle, and the 
peculiar appearance of the urine. 

The diagnosis between stone in the kidney and stone in the blad- 
der seems easy, but it is sometimes difficult. A stone in the blad- 
der, irritating the neck, may cause pain radiating up one, or both 
ureters, and the patient may not be able to define the direction of 
the pain. In stone in the bladder the urine is alkaline, in renal 
stone it is acid. There is more mucus in stone in the bladder, and 
more pus in stone in the kidney. 

It is stated that we may be able to predict the form of calculi 
from the symptoms. The large uric acid calculi less frequently pro- 
duce severe symptoms. Oxalate of lime calculi causes more severe 
radiating pain than the uric acid. In both these forms the urine is 
acid. Phosphatic calculi are said to cause the most intense pain. 
In a case of renal colic extending over several years, and more 
intense than any other in my experience, the stone when voided 
proved to be composed of xanthine. It was sharp, jagged, and very 
irregular. 

Treatment. — Sir William Roberts, in a series of lectures on the 
chemistry and therapeutics of uric acid gravel and gout (" Lancet," 
June 25, 1892), says the treatment of calculous disorders must be 
in the main preventive. " The chemical force which is requisite to 



DISEASES OF THE URINARY SYSTEM. 579 

prevent the precipitation of uric acid in the urinary channels is 
almost infinitely small as compared with the force which is requisite 
to redissolve a concretion already formed. Uric acid gravel is con- 
stantly seen existing per se, in persons who are in all other respects 
perfectly healthy. From a therapeutic point it is a mischievous 
notion that uric acid gravel and gout are substantially the same 
disease. Gravel should be regarded as a primary vice of the uri- 
nary function, and the urine the proper field for its investigation and 
treatment. The author's experiments point strongly to the sugges- 
tion that subjects of gravel should be advised to take as much culi- 
nary salt as their palates will tolerate. The most reliable inves- 
tigations indicate that fat, sugar, and starchy matters have not the 
slightest influence on the production and excretion of uric acid, nor 
has any proof been given that albuminoid substances of vegetable 
origin differ in this respect from albuminoid substances of animal 
origin. The author believes that the free use of farinaceous articles, 
salads, fruits, and garden vegetables, all comparatively poor in albu- 
minous constituents, should be advised. All other schemes of treat- 
ment sink into insignificance in comparison with that of diminishing 
the acidity of the urine. It is chemically impossible for uric acid to 
be deposited from an alkaline urine, and as we have the means of 
harmlessly reducing the acidity of the urine at will, we have in our 
hands, in principle at least, the absolute power of preventing uric 
acid gravel. The risk in gravel is almost confined to precipitations 
which take place within the precincts of the kidneys, and the author 
has found that the most risk of precipitation in the kidneys is dur- 
ing the time of sleep. Therefore, a single dose of citrate or bicar- 
bonate of potash or soda (forty-five to sixty grains dissolved in three 
or four ounces of water), taken at bedtime, suffices for the milder 
cases. In others, a second dose can be taken in the night when the 
patient has a call to empty the bladder. The precipitation can thus 
be postponed until the urine reaches the bladder, whence it is swept 
away, as a rule, before it has a chance to do harm." 

In addition to this excellent advice from such high authority, 1 
advise the free use of pure alkaline, and mildly saline waters which 
contain a minimum quantity of the lime salts, especially the sul- 
phate. Among the pure waters which contain the smallest amount 
of mineral matter, the Poland water of Maine is preeminent. Its 



£80 THE PRACTICE OF MEDICINE. 

value lies in the fact that it comes next to distilled water. In Chi- 
cago the " redistilled " water sold by a reputable ice company is the 
best I know of. If it is not convenient to purchase distilled water, 
the cost of a simple apparatus for distilling is small. In some cases 
the alkaline-saline waters are of more value than distilled water. 
The European and American Vichy waters are valuable. The lithia 
waters now so extensively advertized with fulsome praise may be of 
service in some cases, but only when lithia is really indicated by 
some peculiar symptoms of the patient. None of the natural lithia 
waters contain more than one grain to the gallon. If more is claimed, 
it is probably added. Now we are warned by old-school authorities 
not to give more than three or five grains daily on account of its 
unpleasant action on the heart. Dr. H. C. "Wood (" Therapeutics ") 
says : " In twenty-grain doses I have seen it apparently produce 
severe general prostration amounting almost to general paralysis." 
It would be manifestly dangerous to drink an artificial lithia water 
containing ten or twenty grains to each gallon, as advised by some 
writers. If lithia waters are of value, it is more as a preventive of 
gravel, than for dissolving them in the urinary passages. Because 
lithia dissolves uric acid gravel in the test-tube it does not prove it 
will do the same in the bladder or kidney. But lithia is usually asso- 
ciated with the alkaline carbonates in natural water, and these keep 
the urine alkaline if enough is taken. Besides, lithia has a sedative 
action on the urinary mucous surfaces when taken in small quan- 
tities. 

The natural lithia waters should be drank hot in the morning 
and at night, and cool during the day, and at regular intervals, but 
not during mealtime, except a small tumblerful. If the natural lithia 
waters are not obtainable, give five or ten grains of the lx or 3x 
trituration of the citrate, carbonate, or benzoate of lithia, in a glass 
of distilled water, between meals and at night. 

Piperazin, one of the recent coal tar derivatives, is claimed to be 
more potent than lithia, potash, or any other solvent of uric acid. 
It is freely soluble in water, and in cold aqueous solution will dis- 
solve twelve times as much uric acid as will lithium carbonate. Its 
urate, which is said always to be a neutral salt, is seven times more 
soluble in water than in the corresponding salt of lithia. It is a 
stable compound, apparently not undergoing decomposition in the 



DISEASES OF THE URINARY SYSTEM. 581 

organism. It is readily excreted by the kidneys, and may be detected 
in the urine in a few hours after a single dose. It is claimed that 
piperazin has great curative influence over gout, prevents the forma- 
tion of uric acid calculi, and even dissolves them in the kidney. In 
order to test this claim, Dr. D. D. Stewart, of Jefferson Medical 
College, tried it in a number of cases of uric acid diathesis, with 
renal calculus. In a typical case with a history of almost continuous 
ache in the right loin for nearly a year ; paroxysms of pain shooting 
towards the bladder, occasional passage of gravel, anorexia, consti- 
pation, bad taste, leucorrhoea, painful menstruation, severe headache 
twice a week, melancholy, very acid urine, s. g. 1.028, with excess 
of free acid, microscopic calculi of ammonium urate and uric acid, 
amorphous urates, red blood corpuscles, epithelium from pelvis of 
kidney, no palpable tumor in flanks, but a deep-seated tenderness, 
etc. For two months citrate of potash was given liberally in large 
quantity of hot water, with no improvement. Then a lithia water was 
used freely, with no better results ; meantime there appeared full- 
ness, dullness, and resistence in each flank, and other symptoms of 
stone in the kidney became more pronounced. 

Nephrotomy was advised but not consented to. Owing to the 
very scanty urine, often but seventeen ounces daily, diuretin was 
given, but without effect. Then piperazin was given, fifteen grains 
daily, with surprising effects. After three or four days the amount 
of urine increased to four to six pints daily. The loin pain was 
much diminished, and the fullness and dullness less in area. Her 
general condition improved, appetite and digestion being better than 
for years. In a few months more she seemed perfectly recovered. 
It is a singular fact, observed by Stewart, that piperazin does not 
render the urine alkaline, while it reduces the uric acid to a mini- 
mum, and increases the elimination of urea. 

Many similar cures are reported by German authorities, and the 
drug seems worthy an extended trial. I would suggest the use of the 
lx trituration in ten to thirty grain doses, in distilled or pure water, 
every three hours. There is a solution prepared by a German chem- 
ist which it is claimed has superior merits. We know of no other 
substances which have any power to dissolve uric acid calculi. 

I know from considerable experience that boro-citrate of mag- 
nesia will distin tegrate phosphatic and calcareous stone in the kid- 



582 THE PRACTICE OF MEDICINE. 

ney, and I have reported several notable cases. The doses used 
ranged from five grains of the crude salt to five grains of the lx 
trituration. Often the latter appeared to act best, given of course 
in large quantities of pure water. 

A great many drugs have gained a reputation as solvents of stone, 
or possessing the power of disintegrating and expelling them, but 
such claims are doubtful. They probably act by lessening irritation, 
and relaxing the tissues of the urinary passages. Among them are 
benzoic acid, berberis, epigaea, lycopodium, eupatorium purpureum, 
galium, stigmata maidis, buchu, pichi, shepherd's-purse (thlaspia), 
orthosiphon, hydrangea, actinomeris, onosmodium, chimaphila, liatris 
spicata, eryngium, etc. Under the use of all these, uric acid and 
other calculi of various sizes may have been expelled. When suc- 
cessful, they were usually taken in infusion, cold or hot, and the 
quantity of watery menstrum has been large, which may partially 
account for the favorable results. In some cases, however, I have 
known uric acid sand and gravel to pass out of the bladder under 
the use of small doses of lycopodium, berberis, epigaea, and hydrangea, 
which would seem to show that they possessed some specific influence.* 

Treatment of the Colic. — If the physician is called at the onset 
of the attack, the first object is to reduce the pain. The most prompt 
measure is a hypodermatic injection of one-fourth grain of morphine, 
or one-eighth grain of morphine with l-200th grain of atropine. I 
see no possible objection to this unless some idiosyncrasy of the pa- 
tient forbids it. If morphine is not well borne try one-fourth or one- 
third grain of phosphate of codeine, or hyoscine l-200th grain, or gel- 
semine l-100th grain. If no sedative effect is seen in half an hour the 
dose of the selected drug can be repeated. The medicine can be given 
by the mouth if the injection is objected to, but the relief obtained will 
not appear so quickly. The hot hip-bath, hot wet compresses applied 
to the abdomen and flanks, hot poultices and hot enemata into the 

* Glycerine in large doses has been used by Hermann, with encouraging results, 
for renal lithiasis. It is given dissolved in its own volume of water, at eleven 
o'clock each morning, in dose of fifty to a hundred cubic centimetres. Pains, and 
sometimes attacks of true colic, are produced on the affected side, followed by 
appearance of gravel or calculi in the urine, together with mucus, pus, and perhaps 
blood. After a time the urine becomes normal and attacks cease. The dose is 
repeated two or three days in succession. Temporary cures are certainly made by 
this method. 



DISEASES OF THE URINARY SYSTEM. 583 

howels, may aid in relaxing the ureters so as to allow the stone to 
pass into the bladder. When this occurs the relief is sudden, and 
the sufferer soon sinks into a deep sleep. I have never seen any 
amelioration from dry heat or cupping. It is not best to confine the 
patient to one position, for a change of position often aids the pas- 
sage of the stone. 

The passage of calculi may be aided by the vis a tergo of an in- 
crease of water from the kidneys. Large drafts of hot water or any 
hot beverage are useful. Keyes (" Genito-Urinary Diseases ") says 
the free use of light beer is often efficacious. Many indigenous drugs 
have a reputation in renal colic because they were given in a hot 
infusion, which probably had more to do with the expulsion of the 
stone than the drug itself. A few grains of citrate of lithia or 
piperazin given in a pint of hot water may be of benefit. In this 
way we can give corn-silk, triticum repens, epigasa, buchu, and many 
other plants. It seems to me absurd to claim that minute doses of 
carbonate of calcium, lycopodium, nux vomica, berberis, arnica, bella- 
donna, piper methisticum, etc., can give sudden relief to the intense 
pain of renal colic. Their reputation has been gained by an error 
in judgment, e. g., the physician finds the patient in great pain ; he 
selects some drug which appears to be indicated ; a few doses are 
given, when the pain suddenly ceases — ceases because the stone has 
dropped into the bladder spontaneously, not because the drug has 
anything to do with its expulsion. Besides the active anodynes men- 
tioned above, I think I have seen the pain relieved by dioscorea (es- 
pecially when the pain radiates to distant parts), gelsemium, bella- 
donna, and corn-silk, not in minute doses, but in physiological doses, 
e. g., one teaspoonful in a pint of water, all or part drank at once. 
In a few cases phenacetin or antipyrin, in three-grain doses every 
half-hour, have appeared to mitigate the suffering. 

Dr. C. E. Walton, of Cincinnati, in " The Journal of Orificial 
Surgery," December, 1892, reports some surprising effects from the 
passing of a sound into the bladder in cases of nephritic colic. So 
simple a procedure should not be neglected if future experience veri- 
fies the operation. Dr. Walton writes : 

M He who has stood by the bedside of a patient suffering from 
the agony characteristic of nephritic colic, has seen the strong body 
writhing to relieve itself from the excruciating torture of the pain, 



584 THE PRACTICE OF MEDICINE. 

has heard the harrowing cries involuntarily forced from stoic lips, 
must have felt the need of some remedy less objectionable than mor- 
phine and more potent than the thirtieth dilution of calc. carb. To 
such a one is my message to-day. The means to be suggested has 
passed through the historic stages of most discoveries ; through the 
stage of suggestive hint, of experimentation, of verification, and is 
now waiting for adoption. 

(1) The suggestive hint. A patron of mine had an attack of 
nephritic colic while away from home ; the attending physician had 
the pain hot-compressed, electrocuted, and medicated, but it still per- 
sisted. The great vesical and rectal tenesmus suggested to my 
friend, first, the use of a catheter, and secondly, of an enema. The 
physician was requested to catheterize him, which he did. Just as 
the instrument entered the bladder, the pain was increased and then 
speedily subsided, and in a few moments was gone and has not 
recurred. What caused this relief ? Was the catheterization coin- 
cident with the expelling of a calculus from the ureter, or did the 
stretching of the prostatic urethra cause the dilation of the ureter 
and arrest its spasms ? This could only be determined by experi- 
ment. My knowledge of reflexes led me to believe that the mechan- 
ical stretching was the cause of relief. 

(2) The experiment. Talking of this subject one evening with 
a hotel acquaintance, he mentioned that he had been suffering for 
forty-eight hours, and, except when under the influence of morphine, 
the pain was extreme. I suggested the use of a sound, and the next 
day, when the morphine was failing and the pain reasserting itself, 
I put in a sound and gave him permanent relief in three minutes. 
The experiment was a success. 

(3) The verification. Just about this time I opened a journal 
and, much to my delight, found the account of a physician who had 
stumbled on this mode of treatment after morphine had failed, and 
whilst waiting for chloroform with which to anaesthetize his patient 
he thought it prudent to introduce a catheter to empty the bladder. 
The pain was greatly increased for a moment, and then entirely sub- 
sided ; the chloroform was not needed. This same physician reports 
eight other cases, in all but two of which relief was furnished in 
from one to five minutes. These cases, with my own, surely justify 
the recommendation of the use of the sound in this painful affliction. " 



DISEASES OF THE URINARY SYSTEM. 5S5 

It is claimed by various French authors that the paroxysms of 
pain may be aborted by sandal-wood oil in doses of twenty minims. 
(Mitchell). I have found five-drop doses every hour to relieve the 
dull heavy backache, extending down the ureters, which usually pre- 
cedes the colic. 

Massage given by a competent masseur has been known to facil- 
itate the passage of stone. 

Chloroform or ether may have to be given to partial anaesthesia, 
when in sensitive subjects convulsions appear or are imminent. A 
teaspoonful of chloroform water every ten minutes will relieve some 
severe cases. 

NEPHRITIS (Bright's Disease). 

Eecent pathologists have decreed that acute and chronic inflam- 
mation of the kidneys should be designated acute and chronic Bright's 
disease. It is not quite clear to me why this should be so, unless it 
is to perpetuate the fame of the physician who first wrote a clear 
account of these diseases of the kidneys. Acute and chronic nephri- 
tis was known and described before the time of Dr. Bright, but was 
never before described so well and so clearly. I see no objection, 
however, to the present nomenclature. 

ACUTE DIFFUSE NEPHRITIS. 

Definition. — This may be described as an acute interstitial or 
desquamative nephritis, but in all instances pathological changes 
occur in the vascular, epithelial, or intertubular tissue. The com^ 
mon causes are : (1) Exposure to cold and dampness combined ; 
it rarely occurs from warm dampness. A very common cause is 
exposure to cold, even dry cold, when the body is hot and perspir- 
ing after violent exercise, after drinking freely of liquor, or cooling 
off suddenly with wet clothing on. (2) The poison of all the spe- 
cific fevers, particularly scarlet fever. It may occur after measles, 
small-pox, diphtheria, typhoid fever, cholera, yellow fever, and menin- 
gitis. It has been known to occur during syphilis and tuberculosis 
and as a result of septicaemia. (3) From drugs ; especially those 
which irritate the kidneys. Cantharis, turpentine, chlorate of potas- 
sium, and carbolic acid more frequently cause it than any other, but 



586 THE PRACTICE OF MEDICINE. 

any drug having an affinity for the kidneys, if taken in toxic doses, 
may cause acute nephritis in one of its forms. It has been asserted 
that aloe will cause nephritis, but it has not been proven. Osier 
says, " Alcohol probably never excites an acute nephritis," but we 
know it will cause chronic Bright's disease. 

Morbid Anatomy. — In mild cases the kidneys may present to 
the naked eye no marked change, but in the more severe forms they 
are congested, swollen, dark, and the section may drip blood. In 
severe cases while the surface appears pale and mottled, the capsule 
when stripped off shows the cortex swollen, turbid, and of a grayish- 
red color, and the pyramids of an intense beefy red. The glomerula 
are red, swollen, and congested, or they may be pale. 

Symptoms. — When nephritis follows a chill or a cold from ex- 
posure the onset is sudden. In children convulsions may usher 
in the disease. Chills or rigors are present. Pain in the back, with 
nausea, and vomiting, are often present. It is surprising, however, 
how few painful symptoms are present in acute nephritis. The popu- 
lar idea of inflammation of the kidneys is, that there must be violent 
pain in the back, extending to loins, bladder, and attended by pain- 
ful urination, like the symptoms which occur from renal caculi and 
their passage down the ureters. 

When nephritis follows a cold, dropsy may occur in twenty-four 
hours. After scarlet fever, it appears later, usually during desqua- 
mation, or several days or weeks after, when a puffiness about the 
face, eyes, or ankles is observed. Rarely in adults is there much 
fever, but in children the temperature may for a few days range 
from 101° to 103°. 

It is therefore not the subjective kidney symptoms, but the object- 
ive changes in the urine which will enable us to diagnose the dis- 
ease. The urine may at first be suppressed, though generally it is 
only scanty, very high-colored, containing blood, albumen, and tube- 
casts. The color may vary from a smoky-brown to a porter-red, 
rarely bright red. The specific gravity may be 1.025 or more, and 
the quantity reduced to only two or five ounces in twenty-four hours. 
In children after scarlet fever, often no more than an ounce is passed 
during a day and night. The urine on standing in a cool place 
deposits a heavy sediment. Under the microscope (see Mitchell, or 
Millard on " Diseases of the Kidneys ") are shown blood corpuscles, 



DISEASES OF THE URINARY SYSTEM. 587 

epithelium from the urinary passages, and casts, blood, epithelium 
hyaline or granular in character. Albumen is abundant, forming a 
thick curdy precipitate on boiling and the addition of nitric acid. 
Sometimes this test is not delicate and accurate enough, when other 
and later discovered tests should be used. 

Ansemia is one of the most marked of the early symptoms, and 
persists until the disease is arrested, or increases until death occurs. 
Dropsy is always present ; either general anasarca, or local effusion. 
In nephritis from scarlet fever all forms of dropsy may be present. 
The lungs may become cedematous, effusion may take place into the 
pleura, peritoneum, or pericardium. In some cases the extremities 
only are dropsical. The heart may become rapidly dilated, and this 
aggravates the general dropsical condition. The pulse is often hard, 
the arterial tension increased, and the second aortic sound accentu- 
ated. The skin is dry, and it is very difficult to cause sweating. 

In a few cases uraemic symptoms appear. They may occur at the 
onset when the urine is suppressed, or later when the function of the 
kidneys are almost lost. 

Epistaxis and purpura may set in if the disease is severe. Occu- 
lar changes are not as common as in chronic cases, but they do 
sometimes occur. 

Diagnosis. — Not every case in which albumen, or even tube- 
casts are found in the urine, should be called acute Bright's disease. 
These may appear during transient febrile attacks from the use of 
large doses of drugs, and during pregnancy, without indicating seri- 
ous renal trouble. 

Prognosis. — Under judicious treatment cases caused by cold 
generally recover. Scarlatinal nephritis is more obstinate. In eight 
or ten days, if the progress is favorable, the dropsy diminishes and 
the urine increases, the albumen lessens, and at the end of a month 
the dropsy has disappeared and the urine is normal. In some cases 
recurrent attacks occur from exposure or other causes, ending event- 
ually in chronic Bright's disease. 

Treatment. — It should be borne in mind that the medicinal rem- 
edies for acute nephritis are those drugs which have been known to 
cause it. The old school dimly appreciate this truth, for the few 
drugs which they have found to have any specific value belong to 
that class. Osier makes the astounding assertion that " No remedies, 



588 THE PRACTICE OF MEDICINE. 

so far as known, control directly the changes going on in the kid- 
neys." The difficulty with that school is, however, that owing to 
traditional usage they use doses which generally aggravate the dis- 
ease, but this result rarely influences them to use small and non-irri- 
tating doses. Millard is one of the few who seem to have some idea 
of the true action of small doses. 

The medicines which I have found most effective in acute Bright's 
disease are cantharis, turpentine, oil of sandal-wood, copaiva, pichi, 
apis, equisetum, benzoate of ammonia, and aurum muriaticum. I 
have never found arsenic of the slightest value ; hepar sulphur 
undoubtedly hastens the desquamation, and limits it. In a few cases 
mercurius corrosivus has given good results. I will not give the 
indications, as they are fully given by Lilienthal and Mitchell, except 
for pichi and oil of sandal-wood, of which we have only brief prov- 
ings. The former I consider indicated when blood is found in the 
urine in large quantity, associated with epithelial, waxy, and granular 
casts ; the latter when pain in lumbar region is complained of, and 
the urine is highly albuminous. 

In addition to medicinal agents, dietetic and hygienic treatment is 
indispensable. Drugs alone will not cure a single case. The patient 
should — as soon as we suspect the presence of a nephritis — be put 
to bed, and there remain until all trace of the disease has disappeared. 
He should be clothed in thin fine wool or canton flannel ; sufficient 
woolen blankets should cover him to induce a gentle perspiration all 
the time. If sweating is not induced by them, pilocarpine 2x in two 
or five grain doses every two hours should be given, which rarely fails 
to cause perspiration. The tincture of sambucus niger is also valu- 
able in such cases — ten to fifteen drops every hour. An infusion 
of the flowers, drank hot, is often more effectual. The diet should 
consist of milk, buttermilk, gruels made of arrow root, barley, oat- 
meal, or sago. If the patient is very weak, chicken or lamb broth 
may be permitted, but no beef tea. A milk and water diet is safest 
in bad cases. I always give the milk diluted one-half with Vichy, 
seltzer, Poland, or pure distilled water. It is better borne by the 
stomach and acts better on the kidneys when given with a pure or an 
alkaline water. Lemonade with white of egg acts favorably. The 
addition of one drachm of cream of tartar to a pint of lemonade 
makes it one of the most soothing yet effectual diuretics known. It 



DISEASES OF THE URINARY SYSTEM. 589 

keeps the kidneys flushed and washes out the debris from the tubes ; 
moreover, this beverage keeps the bowels open, which is a very 
important aid to the cure in all cases. Never allow constipation to 
exist. If this drink does not open them flush the colon every day 
with pure boiled water. In adults or young persons, there are some 
adjuvant measures which are valuable. If there is severe pain in 
the back with hematuria, dry cupping over the kidneys will aid the 
action of pichi or cantharis. Hydropathic measures, such as the wet 
pack, the vapor bath, aided by jaborandi or pilocarpine, greatly aid 
in diverting the strain from the kidneys and dispersing the dropsy. 
In adults I have succeeded in averting serious dropsical effusion by 
the use of apocynum, elaterium, or the use of purgative doses of 
Epsom salts — (a teaspoonful or tablespoonful of a saturated solu- 
tion every three or four hours). 

If the arterial tension is high, it is important to lessen it. In 
strong patients veratrum viride will act well. If not, give muriate 
of gold and sodium 2x, one grain every hour until the tension is 
lowered. With this lowered tension diuresis will occur. In a few 
cases I have seen excellent results from glonoine 2x, five to ten 
drops every two hours. 

If the heart is weak and the pulse soft, irregular, or intermitting, 
digitalis, strophanthus, cactus, or adonis are indicated, but never 
when the pulse is small and hard. I have found the tincture of 
muriate of iron or the ethereal tincture of the perchloride indispen- 
sable when there is auaBmia. Two to five drops three times a day 
act well. Other remedies can be given in alteration with it. 



CHRONIC PARENCHYMATOUS NEPHRITIS. 

Definition. — This includes chronic desquamative, and chronic 
tubal nephritis ; and chronic diffuse nephritis with exudation. 

These conditions may follow acute nephritis from cold, scarlet 
fever, or pregnancy, but more frequently they come on insidiously 
as the sequel of fevers. Beer and alcohol are thought to cause many 
cases. I believe that excessive beef -eating is a common cause. I 
doubt if tuberculosis or malaria ever cause this disease, but I am 
convinced from many observations that syphilis is more often a cause 
than is generally supposed. 



590 THE PRACTICE OF MEDICINE. 

Morbid Anatomy. — There are three varieties of this form of 
nephritis. 

(1) The large white kidney, in which the organ is enlarged, the 
capsule thin, and the surface white, with the stellate veins injected. 
On section the cortex is swollen and yellowish white in color, and 
often presents opaque areas. The pyramids may be deeply injected. 
The epithelium is granular and fatty, the tubules of the cortex dis- 
tended, containing tube-casts. The interstitial tissue is everywhere 
increased. 

(2) The small white kidney, or pale granular kidney, in which, 
after an increase in the connective tissue, a shrinkage occurs. It 
may not always be preceded by enlargement, and may be a primary 
form. When cut into it is found that the normal resistance is greatly 
increased, the cortex reduced, presenting numerous opaque, white, or 
whitish yellow foci consisting of fatty epithelium in the convoluted 
tubes. It seems to be a combination of contracted kidney with areas 
of marked fatty degeneration. 

(3) Chronic hemorrhagic nephritis, in which the organs are 
enlarged, yellowish white in color, and in the cortex many brownish 
red areas due to hemorrhage into and around the tubes. 

Symirtoms. — These varieties generally follow an acute nephritis. 
They may, however, come on insidiously. After an attack of dys- 
pepsia or a period of failing health the patient becomes pale and 
weak, and puffin ess of the eyelids and swollen feet are noticed in the 
mornings. The urine is usually diminished, often very scanty. It 
has a dirty yellow, smoky color, and is turbid with urates. In the 
heavy sediment which falls after standing are found many tube-casts 
of various forms and sizes, hyaline, granular, fatty, and epithelial. 
Leucocytes are abundant. Blood globules are frequent. Albu- 
men is abundant ; sometimes nearly one-half or two-thirds of the 
urine, especially in the day urine. The specific gravity is high. 
Dropsy is always a marked and obstinate symptom. The face is 
pale and puffy, the eyelids are quite cedematous in the morning. 
Anasarca is general, and there is effusion into the serous sacs. The 
pulse-tension is usually increased, the blood-vessels become stiff, 
and the heart is hypertrophied. In many cases there are retinal 
changes. Vomiting and diarrhoea are frequent. It is sometimes 
impossible to diagnose by the symptoms the presence of one form 



DISEASES OF THE URINARY SYSTEM. 591 

of this disease from the other — the large from the small kidney. 

Treatment, — The diet and regimen recommended for acute neph- 
ritis is applicable to these forms. The remedies are the same, espe- 
cially aurum, glonoine, amyl, kali-cobalto nitrite, and pilocarpine* 
when arterial tension and enlarged heart exists. 

Apis, mercurius corrosivus, helonias, sepia, arsenic, apocynum, 
and perchloride of iron, in the large white kidney. 

Phosphorus, plumbum, berberis, euonymin, arsenite of antimony, 
and argentum, in contracted kidney. 

Turpentine, erigeron, millefoil, coccus cacti, and pichi in the hem- 
orrhagic kidney. The patient should seek a warm, moist but non- 
malarious climate, and reside there until he is cured. 



CHRONIC INTERSTITIAL NEPHRITIS. 

This includes those forms which have been designated contracted 
kidney, granular kidney, cirrhosis of the kidney, gouty kidney, and 
sclerotic kidney. 

There are three varieties of sclerotic kidney : (1) the pale gran- 
ular or secondary contracted kidney, a sequence of the large white 
kidney ; (2) an independent primary disease ; (3) a result of arte- 
riosclerosis. 

These forms of Bright's disease are the most frequently met with, 
and constitute nine-tenths of all cases coming under treatment. It 
seems to be a hereditary disease in some families. In many cases 
no satisfactory cause can be assigned. Syphilis, alcohol, beef-eating, 
lead-poisoning, drugging with patent medicines recommended for 
Bright's disease, lithaemia, gout, a cold and damp climate, and, above 
all, intense worry and strain of business, with hurried eating and 
lack of exercise, are the chief known causes. 

The arterio-sclerosis which comes with premature or natural old 
age is a prominent factor in the causation of Bright's disease. 

The morbid anatomy of this form is briefly described as follows 
by Osier : " The kidneys are usually small, and together may weigh 
no more than an ounce and a half. The capsule is thick and adhe- 
rent ; the surface of the organ irregular and covered with small nod- 
ules, which have given to it the name of granular kidney. In strip- 



592 THE PRACTICE OF MEDICINE. 

ping off the capsule, portions of the kidney substance are removed. 
Small cysts are frequently seen on the surface. The color is usually 
reddish, often a very dark red. On section the substance is tough 
and resists cutting ; the cortex is thin, and may measure no more 
than a couple of millimetres. The pyramids are less wasted. The 
small arteries are greatly thickened and stand out prominently. The 
fat about the pelvis is greatly increased. 

"Microscopically there is seen a marked increase in the connective 
tissue and degeneration and atrophy of the secreting structures, glom- 
erular and tubal, the former being most predominant and giving the 
main characters to the lesion." . . . " The view most generally 
entertained at present is that the essential lesion is in the secreting 
tissues of the tubules and the glomeruli, and that the connective-tis- 
sue overgrowth is secondary to this. Greenfield holds that the pri- 
mary change is in most instances in the glomeruli, to which both the 
degeneration in the epithelium of the convoluted tubules and the 
increase in the intertubular connective tissue are secondary." 

" Associated with contracted kidney are general arterio-sclerosis 
and hypertrophy of the heart. The changes in the arteries will be 
described in the section on arterio-sclerosis. The hypertrophy of the 
heart is almost constant. I do not remember ever to have seen a 
well-marked instance of contracted kidney without some hypertrophy 
of the left ventricle, and the enlargement may reach an extreme 
grade. The variations depend, no doubt, in part upon the extent of 
the diffuse arterial degeneration, and there are instances in which the 
term cor bovinum may be applied to the enlarged organ. In such 
cases the hypertrophy is not confined to the left ventricle, but involves 
the entire heart. The explanation of this hypertrophy has been 
much discussed. It was at first held to be due to the increased work 
thrown upon the organ in driving the impure blood through the cap- 
illary system. Basing his opinion upon the supposed muscular 
increase in the smaller arteries, Johnson regarded the hypertrophy as 
effort to overcome a sort of stop-cock action of these vessels, which, 
under the influence of the irritating ingredient in the blood, con- 
tracted and increased greatly the peripheral resistance. Traube 
believed that the obliteration of a large number of capillary terri- 
tories in the kidney materially raised the arterial pressure, and in 
this way led to the hypertrophy of the heart ; an additional factor, 



DISEASES OF THE URINARY SYSTEM. 593 

lie thought, was the diminished excretion of water, which also height- 
ened the pressure within the blood-vessels." 

" In our present knowledge the most satisfactory explanation is 
that given by Cohnheim, which is thus clearly and succinctly put by 
Fagge : He gives reasons for thinking that the activity of the cir- 
culation through the kidneys at any moment — in other words, the 
state of the smaller renal arteries as regards contraction or dila- 
tation — depends not (as in the case of the tissues generally) upon the 
need of those organs for blood, but solely upon the amount of mate- 
rial for the urinary secretion that the circulatory fluids happen then 
to contain. This suggestion has bearings upon the development of 
hypertrophy in one kidney when the other has been entirely destroyed. 
But another consequence deducible from it is that when parts of one 
kidney have undergone atrophy, the blood-flow to the parts that 
remain must, caeteris paribus, be as great as it would have been to 
the whole of the organs if they had been intact. But in order that 
such a quantity of blood should pass through the restricted capillary 
area now open to it, an excessive pressure must obviously be necessary. 
This can be brought to bear only by the exertion of more than the nor- 
mal degree of force on the part of the left ventricle, combined with 
the maintainance of a corresponding resistance in all other districts 
of the arterial system. And so one can account at once for the high 
arterial pressure and for the cardio-vascular changes that are sec- 
ondary to it." (Osier.) 

Symptoms. — The insidious nature of this disease, and its approach, 
are such that it is rarely recognized until the occurrence of one of the 
serious or fatal complications. An advanced grade of contracted 
kidney may be compatible with great mental and bodily vigor. 
There may have been no prominent symptoms to suggest the pres- 
ence of a serious disease. So varied and complicated is the clinical 
picture of Bright 's disease that it is considered best by nearly all 
writers to take up the symptoms under the various systems ; which 
I shall do. 

(1) The Urinary System. — The amount of urine is usually in- 
creased. The frequency is also augmented. The patient has to get 
up two or three times at night to empty the bladder. There is nearly 
always increased thirst. Generally relief is at first sought for these 
symptoms. But it should be remembered that frequent urination at 

38 



594 THE PRACTICE OF MEDICINE. 

night is also a symptom of irritable bladder or prostrate, or hyper- 
acidity of the urine. The urine is clear, light yellow, with no appre- 
ciable sediment, and the mucous cloud is well marked. The specific 
gravity ranges from 1.005 to 1.012. Traces of albumen are found, 
especially in the morning. In the scanty sediment only a few hyal- 
ine or granular casts are found. The solid constituents of the urine 
are generally diminished. Occasionally blood occurs in the urine, 
and rarely hematuria. 

(2) Circulatory System. — The tension is generally increased 
and the artery stiff. The pulse is hard, showing thickening of the 
vessel wall. The pulse of increased tension has the following char- 
acters : It is hard and incompressible, requiring a good deal of force 
to overcome it. It may be impossible to obliterate the pulse-wave. 
It is persistent and in the intervals between the beats the vessel can 
be rolled like a cord under the finger. The pulse may be hard and 
of high tension, however, when the wall of the vessel is not thick- 
ened. 

Fibroid arterio-sclerosis is not necessarily a cause of this high 
tension. Dr. Broadbent says : " It will, then, be taken as proved 
that the high arterial tension of contracted granular kidney is due 
to arterio-capillary contraction, and not to arterio-capillary fibrosis 
or degeneration, the contraction being provoked by the presence in 
the blood of some matter which acts as an irritant. The fact that 
increased blood-pressure often precedes the kidney mischief shows 
that it is not due purely and simply to deficient renal elimination, 
but it cannot be doubted that, when disease of the kidneys is estab- 
lished, the retention in the blood of waste products which ought to 
have passed out of the system by these organs adds to opposition in 
the capillaries, and becomes an important factor, perhaps the most 
considerable factor, in the production of the high arterial tension. 
Additional certainty is given to this conclusion by the fact that 
other affections of the kidneys at once give rise to increased blood- 
pressure, and that it is in chronic Bright' s disease that arterial ten- 
sion reaches its maximum." The heart sympathizes with this high- 
pulse tension. Dr. Broadbent clearly describes the heart's condi- 
tion as follows : " Cooperating with the arterio-capillary resistance 
to produce the renal pulse, so-called, is an increased propulsive 
power of the heart. The gradual advance of the renal changes and 



DISEASES OF THE URINARY SYSTEM. 593 

of the peripheral obstruction to the circulation in chronic Bright's 
disease affords time for the heart to accommodate itself to the 
increased work thrown upon it, and to meet the resistance in the 
arterio-capillary network by hypertrophy. That the hypertrophy is 
a real increase of the cardiac muscular fibres and not merely an addi- 
tion of adventitious fibrous tissue there can be no manner of doubt : 
it is demonstrated by the microscope and proved by the increase of 
functional energy. In the late stages of the disease, when the heart 
is worn out, an excess of fibroid material is present, and the propor- 
tion at all periods will vary according to individual tendencies and 
mode of life ; it may be larger, for example, in cases of alcoholism, 
but the characteristic change in the heart is true muscular hyper- 
trophy, the result of excessive functional exercise. 

The apex-beat is displaced downwards to the sixth or even the 
seventh space, and carried somewhat outwards ; it is a genuine thrust, 
and not a mere shock, and the cardiac impulse generally is powerful. 
The first sound, as heard at the apex, is dull and prolonged, while 
over the aortic area it is scarcely, if at all, audible. At an advanced 
period of the disease, when the heart has begun to suffer from the 
effects of protracted over-work, and in some cases throughout, the 
first sound is reduplicated over a larger or smaller area near the 
apex. The aortic second sound is loud and accentuated both in the 
right second space and at and to the left of the apex. It would 
almost appear from the considerations stated that the heart and ves- 
sels were engaged in a work of mutual destruction, and such is in- 
deed Lhe fact, as is testified by cerebral hemorrhage and valvular and 
structural disease of the heart. It is, however, probable that other 
evils are averted which would prove fatal sooner, and that high arte- 
rial tension is really the result of a defensive reaction." 

(3) Respiratory System. — CEdema of the glottis or of the lungs 
may occur suddenly, also effusion into the pleurae. Acute pleurisy 
and pneumonia are common. Bronchitis may occur, especially in 
winter. Dyspnoea at night is not infrequent. This may be an urae- 
mic or a cardiac symptom. Cheyne-Stokes breathing generally ap- 
pears toward the close, but sometimes when the patient is up and 
walking about. 

(4) Digestive System. — Uncontrollable vomiting may be the 
first symptom of a serious nature. This is generally believed to be 



596 THE PRACTICE OF MEDICINE. 

due to ursemia. It has been known to be fatal before there was any 
suspicion of chronic Bright's disease. Dyspepsia and loss of appe- 
tite is generally present. Severe and even fatal diarrhoea has been 
known to occur. 

(5) Nervous System.— Cerebral apoplexy is a common concom- 
itant of interstitial nephritis. The mind may be clouded, and the 
patient become insane, have hallucinations and illusions. Neuralgias 
are often severe and intractable. 

(6) Eyes. — Abnormal conditions of vision are often the first 
symptom of the disease. The opthalmologist often discovers the 
presence of Bright's disease before it is suspected by the regular 
attendant. Sudden blindness may occur before retinal changes. 

(7) Ears. — Ringing in the ears ; various forms of deafness ; and 
other auditory troubles often attend the disease. 

(8) The Shin is dry and pale ; the patient rarely sweats, and 
when he does a white frost of urea may be deposited on the surface. 
Eczema is a common accompaniment. The fingers may be numb and 
tingling, and are cold. Epistaxis and other hemorrhages are frequent. 
Intolerable itching and muscular cramps are not uncommon. Asci- 
tes and oedema of the skin are rare, unless there is cirrosis of the 
liver. 

Diagnosis. — The early stages of interstitial nephritis is rarely 
recognized. Osier gives the following important indications of the 
presence of this disease : " In a patient with increased pulse-tension 
(particularly if the vessel wall is sclerotic), with the apex-beat of 
the heart dislocated to the left, the second aortic sound ringing and 
accentuated, the urine abundant and of low specific gravity, with a 
trace of albumen and an occasional hyaline or granular cast, the diag- 
nosis of interstitial nephritis may be safely made. Of all the indi- 
cations, that offered by the pulse is the most important. Persistent 
high tension with thickening of the arterial wall in a man under fifty 
means that serious mischief has already taken place, that cardio-vas- 
cular changes are certainly, and renal most probably, present. It 
is important in the diagnosis of this condition not to rest content with 
a single examination of the urine. Both the evening and morning 
secretion should be studied. The sediment must be collected in a 
conical glass, and in looking for tube-casts a large surface should be 
examined with a tolerable low power and little light. The arterio- 



DISEASES OF THE URINARY SYSTEM. 597 

sclerotic kidney may exist for a long time without the occurrence of 
albumen, or the albumen may be in very small quantities. In many 
cases it is impossible to differentiate the primary interstitial nephritis 
from an arteriosclerotic kidney, nor clinically is it of any special 
value so to do. In persons under forty, with very high tension, great 
thickening of the superficial arteries, and marked hypertrophy of 
the heart, the renal are more likely to be secondary to the arterial 
changes." 

Prognosis. — Old-school authorities take very pessimistic views 
of the curability of chronic Bright's disease. They consider it " an 
incurable affection, and as much beyond the reach of medicines as 
wrinkled skin and gray hair." The homeopathic school are too opti- 
mistic. Buchner in his " Morbus Brightii " implies that a large pro- 
portion of cases are curable " if we can find the true homeopathic 
remedy." When we consider how obscure and unrecognizable are 
the symptoms, we can only look on this assertion as an excuse 
unworthy an honest writer. If we include all forms, the acute as 
well as chronic, I am willing to admit that we may cure a larger pro- 
portion of cases than the old school. We certainly have more potent 
palliative remedies, and can lengthen the duration of life by their 
judicious use. Because a man has increased arterial tension, with or 
without thickening of the arterial walls, polyuria with a small amount 
of albumen, and a few hyaline casts, we must not condemn him to 
die or abandon the pursuits of an active life. We may hold the 
disease in check, and ward off the fatal end, but we cannot promise 
a cure. 

Treatment. — The only work on the treatment of this disease which 
has yet appeared in our school — " Buchner on Morbus Brightii " — 
is of small value, on account of its confounding the acute with the 
chronic malady. The indications for medicines are confusing, im- 
practical, and largely theoretical. Dr. C. Mitchell gives a better 
resume of the treatment, but it is by no means complete nor was it 
intended to be, as his work was intended more as a work on diag- 
nosis, than treatment. Millard's is the most practical work, and the 
treatment is liberal and free from sectarian bigotry. The hygienic 
treatment is of the greatest importance. So soon as the disease is 
discovered the patient should so regulate his life as to throw the least 
possible strain on the kidneys, heart, and arteries. A quiet life with- 



598 THE PRACTICE OF MEDICINE. 

out mental worry, free from the excitement of speculation or money- 
making, is all-important. A residence in an equitable climate, 
according to Purdy, is the best preventive of fatal results. Purdy's 
researches show that the largest mortality from Bright's disease 
occur in the New England and Northern States — in the region of 
the Great Lakes, — - and the lowest mortality in the Gulf and lower 
Atlantic States. I believe Georgia, Florida, and Alabama are the 
best states for sufferers from this disease, and lower Florida probably 
the best of all locations. In no disease is it so important to see that 
the normal functions of the skin are performed. This is not con- 
duced by frequent washing with soaps, which destroy the natural oil 
of the skin, but by daily sponging with pure soft water, followed by 
a good rubbing and inunction with some pure vegetable or animal 
oil. An occasional Turkish bath, under due precautions, followed 
by inunctions of oil, is not objectionable. I have traced many cases 
of Bright's disease back to a Turkish bath followed by exposure to 
cold and dampness or a ride in an open street-car or carriage. 

Woolen underclothing is indispensible in all climates, the tropi- 
cal as well as temperate, in order to guard against a chill from 
change of temperature at night, or after exercise. 

The best beverage is pure spring water. There are no " mineral 
waters " which have any curative influence over this disease. The 
much vaunted waters of Waukesha, Poland, Bedford, Saratoga, 
Yichy, and Carlsbad are only valuable because they are pure water, 
and as such help the interstitial circulation and keep the drains 
flushed. The less mineral matter the water contains, the better it is 
for this purpose. 

The diet should be nourishing but light. Meat should be eaten 
but once a day, and beef should be rarely if ever eaten. Each meal 
should be light — never a surfeit. Tea and coffee can be taken, but 
alcohol rarely if ever. It is a lamentable mistake to send patients 
with this disease to drink the waters of fashionable places of resort. 
They live in crowded hotels, take but little exercise, eat and smoke 
too much, sleep in close rooms, and lounge on piazzas. 

Pure water can be taken as well at home, or in the country 
where there is fresh air, no excitement, and no temptation to over- 
eating. 

A summing up of the opinion of the best authorities seems to be 



DISEASES OF THE URINARY SYSTEM. 599 

this : The best diet is an almost exclusive milk diet. The argu- 
ments in favor of this diet are : (1) Milk is easily assimilated and 
is therefore well adapted to a disease in which digestive disturbances 
are almost the invariable rule. (2) If a suitable amount of milk 
be taken daily it provides sufficient nutriment for the needs and 
proper support of the economy. (3) An exclusive milk diet forms 
less urea in the blood than any other form of alimentation. (4) 
Milk furnishes a large quantity of fluid to flush out the kidneys 
with, always supposing it is taken at short intervals and in fairly 
large quantities at a time. In this way it excites urinary secretion 
by continued excessive pressure in the arterial system, and this helps 
the dropsy to disappear by degrees. 

Milk will be most beneficial if taken fresh from the cow, or 
unskimmed, for thereby we get the fats which greatly aid in the 
general nutrition. If it is not well tolerated, giving rise to pyrosis, 
acidity, heartburn, and gases, it may be peptonized by Fair child's 
processes. If then it is not well borne, skimmed milk should be 
used, and in addition, eggs to supply the demand for oil and albu- 
men. There are some persons who seem to have an idiosyncrasy 
against milk. This is often imaginary, but sometimes very real, 
milk seeming to act almost as a poison, just as white of egg does on 
some persons. I have found in such cases that malted milk will 
agree and can be taken in sufficient quantity. Koumiss is some- 
times a good substitute for milk, and the slight quantity of alcohol 
it contains is specially adapted to cases in which there is great 
debility, and a delicate stomach. If milk disagrees when taken 
alone, it will not when mixed with equal parts of Yichy, Seltzer, or 
Deep Rock water. Milk if violently shaken a minute or two will be 
tolerated when unshaken milk is not. If an exclusive milk diet be 
insisted on, the amount taken during twenty-four hours should not 
be less than three or more than five quarts. It may be taken hot, 
warm, or cold, to suit the taste of the patient. When the stomach 
is very irritable it can be iced, and taken in very small quantities — 
an ounce every half-hour. In an exclusive milk diet it should be 
taken in fixed quantities and at specified hours. From a few ounces 
to half a pint or a pint, every two or three hours in an adult. If a 
mixed diet is adopted, milk should be alternated with potatoes, in 
soup or mashed ; gruels of arrow-root, rice, granola, wheatena, corn 



600 THE PRACTICE OF MEDICINE. 

and oat meal ; fat bacon, butter, zwiebach, broths of chicken, lamb, 
mutton, clam, and oysters. 

There are several authorities, among them Stuart, that insist on 
a mixed diet, and even advise the use of meats and other nitrogen- 
ized food, in order to support the strength of the patient. Others, 
like Beaumetz, insist on a strict diet of milk and vegetables. It has 
been asserted by many, among them Senator, that albuminous food 
should be prohibited, on the same ground that sugar is forbidden in 
diabetes, but there is really no analogy. The treatment of chronic 
Bright's disease by special forms of diet has recently been the sub- 
ject of a series of investigations by Professor Schreiber, of Koenigs- 
berg, whose results are of some interest in view of the present posi- 
tion of the question. He traverses Senator's statement that one 
ought in cases of albuminuria to forbid the use of eggs, holding that 
their injurious influence is open to question. ( u The Practitioner.") 
He took for purpose of experiment eight people suffering from kid- 
ney disease, to whom he gave along with their ordinary diet six to 
ten eggs daily. Before the beginning of the experiment they had been 
under observation from four to eight days, on the usual diet, until 
the fluctuation in the amount of albumen in the twenty-four hours 
had been determined ; the estimations being likewise made for several 
days after the eggs were discontinued. 

" In four of the cases the eggs were administered boiled ; in the 
others raw. In the former group the patient received six eggs daily, 
and in none of them during the period of administration of the nitro- 
genous food could any fluctuation or increase in the amount of albu- 
men be determined. In the second group six to ten raw eggs daily 
not only did not show an increase in the excretion of albumen, but 
actually led to a considerable diminution. Similar results have also 
recently been recorded from Leyden's wards. These observations 
also agree with those of CErtel, who has stated that the addition of 
a great quantity of albuminous food may affect albuminuria favora- 
bly. Schreiber maintains that none of the three forms of diet, 
mixed, meat, or milk, appears to be capable of influencing constantly 
and unmistakably the excretion of albumen in kidney disease — a 
result he thinks, although really negative, to be nevertheless received 
with satisfaction when one considers that patients can never stand 
for any time a one-sided diet. In discussing the question how a 



DISEASES OF THE URINARY SYSTEM. 601 

patient suffering from Bright's disease ought to be dieted, Schreiber 
recommends that to an ordinary mixed diet should be added fluid 
or coagulated albumen, meat, and other nitrogenous substances, and 
as there is not less albumen passed under a pure milk diet than 
under a nitrogenous one, it succeeds better to combine the two and 
adds to the body weight. A special diet for Bright's disease is not 
in the least indicated ; it ought to be founded on the broadest basis, 
bearing in mind that the disease is an affection gradually and stead- 
ily consuming the bodily strength ; while the forms of diet should 
be given according to the want and necessity, and without the unjus- 
tifiable and exclusive endeavor to compensate or change the loss of 
albumen by the urine." 

Medicinal Treatment. — There are no specific remedies for that 
composite condition known as Bright's disease. No known drug will 
cause the totality of the symptoms found in that disease. We must 
treat the manifestations as they arise. 

High arterial tension being the most prominent symptom, we 
should direct our efforts to bring it down to a normal. I do not here 
refer to the high tension of arterio-sclerosis, which will be treated of 
in another place. The high tension of Bright's disease is rarely due 
to the latter, but generally to the presence in the blood of imper- 
fectly oxydized nitrogenous wastes. The object of treatment must 
obviously be to keep the blood free from such impurities. Exercise 
and fresh air are of great importance for this purpose, and a per- 
sistent neglect of these essentials to health will defeat any attempt 
to rectify permanently a tendency to high pressure in the arterial 
system. Horse-back riding affords the best means of gaining this 
end. As I observed above, the greatest source of nitrogenized waste 
is the consumption of an undue amount of nitrogenized food. This 
should be limited to a minimum compatible with the health and 
vigor of the patient. All meats come under this head, the most 
injurious being beef ; but mutton, fowl, and game cannot be eaten 
with impunity. Soups, owing to the large quantity of extractive 
meat matters they contain, should be sparingly used. Broadbent 
calls attention to the fact that in some cases high pressure in the 
arteries may be simply one result of a general superabundance of 
fluid in the blood and tissues, and that it may be necessary to reduce 
the volumes of blood by restricting the amount of liquid drank. 



602 THE PRACTICE OF MEDICINE. 

When drink is limited, the restriction should apply especially to 
meal-times. Between meals the effect of drinking water is very dif- 
ferent from when it is taken with food. Water in considerable quan- 
tity, when taken on an empty stomach, flushes the secreting glands 
and washes out the tissues, and is thus a valuable means of elim- 
inating impurities. The best time for drinking is night and morn- 
ing, and the effects are greater when fluid is taken hot. At night, 
hot water stimulates the stomach to contract, gases are expelled, and 
undigested contents swept on into the duodenum, and usually there 
is a general relaxation of the arterioles — in this way it often con- 
duces to sleep. In the morning it is rapidly absorbed and has a 
greater effect on the glands and tissues. If the patient is sent to 
drink the water of springs, or if he takes them at home, he should 
be directed to rise early, drink one or two glasses of the water, hot, 
an hour before breakfast, and walk ten or fifteen minutes. This will 
enable the water to promote blood and tissue metabolism, and carry 
off waste products. 

The best medicinal eliminant is potash and its salts, and Broad- 
bent asserts that liquor potassse is better than the salts, and that the 
carbonate is better than the citrate, the citrate and acetate better 
than the phosphate, nitrate, or sulphate. The soda salts have some 
eliminant influence, but cannot be compared with the potash. Ten 
to twenty grains of any of the potash salts in a glass of hot water, 
on rising in the morning or on going to bed, is sufficient. 

A few of our school still object to the use of these quantities, for 
the insufficient reason that they are " not homeopathic." No one 
supposes they are. They act chemically and mechanically, and their 
action has no more to do with the law of similia than does the food 
we eat, or the air we breathe. The aid they give us, when taken 
with water, is so great and beneficial that we cannot afford to neg- 
lect them. We have no medicines which are homeopathic to the 
high arterial tension similar to that occurring in Bright's disease. 
Digitalis, strophanthus, ergot, and a few others, contract the arte- 
ries, but they act through the vaso-motor system, do not cause reten- 
tion of waste in the blood, and cannot be used to advantage in renal 
high-arterial tension. We must therefore rely on those drugs which 
physiologically dilate the arteries by acting on the vaso-motor cen- 
tres ; or clearing the blood and tissues of waste matters. Those 



DISEASES OF THE URINARY SYSTEM. 603 

belonging to the first class are nitroglycerine, nitrites of sodium 
and potassium, chloride of gold and sodium, chloral hydrate, and 
veratrum viride. The best of these is glonoine, which can be given 
in doses varying from l-200th to l-25th of a grain three times a 
day. No regular dose can be advised, owing to the varying suscep- 
tibilities of individuals. In some, l-200th of a grain (one-half drop 
of the one per cent solution) will cause its peculiar physiological 
effects. In others it will require 1-2 0th of a grain. Several cases 
of high arterial tension have been reported where it required one 
grain a day to relax the contracted and rigid arteries. 

The nitrites of sodium and potassium may be given in doses of 
one to five grains of the Ix trituration, the cobalto-nitrite in doses of 
one-eighth to one-half of a grain, and the chloride of gold and sodium 
in doses of l-100th or l-20th of a grain (one to five grains of the 2x 
trituration). Whichever medicine is given it must be pushed until 
its relaxing effect is produced, and when the normal tension is pres- 
ent the dose may be slightly decreased. Osier and others have given 
glonoine for many weeks, and observed none but the best effects. 
I usually give it a week or two, then suspend its use a few days to 
see if the good effects continue. If not I order it resumed. Those 
drugs which relax arterial tension through their eliminant action, 
probably acting through the agency of the liver, are mercurius, 
euonymin, iridin, chelidonium, carduus, podophyllin, and a few others 
of that class. Probably the drug which acts the most promptly is 
mercurius dulcis (the calomel of the old school). Again and again 
have I seen the high arterial tension of Bright's disease become 
lowered by repeated doses of the 2x, given until some laxative action 
was produced. In cases of long standing the lx is required in doses 
of one to ten grains repeated every two hours. If the case was 
urgent I have not hesitated to give two or three doses of five grains 
each. Dr. Broadbent, in his monograph on "The Pulse," says: 
" An attack of apoplexy may be staved off by a timely dose of cal- 
omel, and by the same means a laboring heart, unable to cope with 
the resistance in the arterioles and capillaries, may at once be relieved. 
The great remedy for mischief of any kind impending as a result of 
kigh blood-pressure is a mercurial purge. The effect of rnercury 
•employed as an aperient upon abnormal tension in the arteries is a 
matter of observation, The method by which the effect is produced 



604 THE PRACTICE OF MEDICINE. 

is a question of hypothesis, but there can be no doubt that it is by elim- 
ination, and there need be but little hesitation in concluding that 
the seat of the accelerated metabolism, of which the elimination is a 
resultant, is the liver. Such, at any rate, is the working hypothesis 
by which I am guided. It may be added, perhaps, that I entered 
upon the independent study of medicine fully impressed with the 
view of teachers held in high respect and confidence, who considered 
that the action of mercury on the liver had been entirely disproved, 
and that mercury, indeed, has practically no useful place in medi- 
cine, and that it has been from my experience of its effects on blood- 
pressure that I have come to value it as one of our most important 
remedies. Full doses of calomel being reserved for emergencies, the 
less serious symptoms may be met by the administration of a single 
grain of a pill of mercury with ipecac, and rhubarb or colocynth 
twice or three times a week, with which may be combined from time 
to time a three-weeks' course of mild salines. To intermediate de- 
grees of urgency may be adapted suitable doses and combinations." 
Many of our school will cavil at this treatment. If they can do as 
well with infinitesimals let them publish their experience. 

Euonymin is one of our best remedies for the high arterial tension 
of Bright's disease. Dr. W. H. Holcombe reports a rapid reduc- 
tion of albumen with general improvement in a patient with Bright's 
disease. Taken in doses of the one-hundredth or one-tenth grain 
four times a day, with the morning and evening use of hot water, 
with phosphate of soda or Carlsbad salts, its beneficial action will 
soon show itself. 

Yeratrum viride has been rarely used by either school, except in 
fevers, but it is invaluable in many cases of high arterial tension. 
When the pulse is hard and unyielding, and the heart action denotes 
beginning or established enlargement with thickening of the walls of 
the ventricles, then this drug is indispensible. Begin with ten drops of 
the 2x, and in a few days, if the tension is not reduced, give ten drops 
of the lx every two or three hours, which will soon produce a large, 
soft pulse. Beyond this normal pulse do not go, for, as Osier observes, 
a certain increase of tension is not only necessary but unavoidable 
in chronic Bright's disease, and probably the most serious danger is 
too great lowering of the blood-tension. The happy medium must 
be sought between the heightened tension that throws a serious strain 



DISEASES OF TEE URINARY SYSTEM. 605 

upon the heart and risks rupture of the vessels, and the low tension 
that under these circumstances is liable to be associated with serous 
effusions. 

I have known great high tension suddenly give way to too low 
tension, not caused by medicines, but by too great a strain. This 
condition simulates the secondary effects of digitalis and its analogues. 
This is their sphere of curative action, when they will prevent serous 
effusions. 

Albuminuria, next to the high arterial tension, and as a conse- 
quence thereof, is perhaps the most important symptom of Bright's 
disease. The drain of albumen from the blood is the greatest cause 
of the anaemia and prostration. If by any means we can lessen or 
arrest the waste of albumen we can save the vigor of our patient. 
The presence of albumen is due to the high arterial tension, and to 
an irritation of the kidneys. While we give medicines to lower the 
tension to normal we must see that the food or beverages of the 
patient do not irritate the kidneys. The albuminoid foods should not 
be taken in excess ; neither should nitrogenous foods, for they raise 
the arterial tension. A vegetable diet diminishes the excretion. Rest 
diminishes the amount of albumen ; fatigue increases it. Cold bath- 
ing increases it, also mental labor. Sexual excitement greatly 
increases its excretion. 

Have medicines any influence on the excretion of albumen? Brun- 
ton says digitalis and strychnine cause it. Allen gives in " Index of 
Symptoms " of his " Encyclopaedia of Pure Materia Medica " the 
following as causing albuminous urine : Absinthe, alcohol, ammonia 
(caustic), antimony, blatta, cantharis, carbolic acid, carbon disul- 
phide, copaiva, sulphur of copper, glonoine, iodine, chlorate of potas- 
sium, corrosive mercury, morphine, muriatic acid, muriate of sodium, 
osmium, petroleum, phosphorus, phytolacca, plumbum, pulsatilla 
ricinus, secale, sulphuric acid, tobacco, taxus, and uranium. It is 
among these medieines that we should expect to find our remedies 
to check the excretion of albumin. Doubtless nearly all of them are 
homeopathic to albuminuria, although some are of doubtful value. 
When it is remembered that even in the hands of an expert, albu- 
min is sometimes difficult to detect, and that many substances simu- 
late albumin and may deceive one not an expert, we are naturally 
skeptical of the value of statements made by provers. However, it 



606 THE PRACTICE OF MEDICINE. 

is a fact that cantharis, copaiva, corrosive mercury, cyanide of mer- 
cury, phosphorus, phytolacca, petroleum and plumbum, have been 
capable of checking the secretion of albumin. 

Empirically it has been proven that muriate of gold, muriate of 
iron, iodide of potassium, bromide of strontium, equisetum, cubebs, 
turpentine, sandal- wood oil, apis mel., and many other renal irritants, 
have been found to check the excretion of albumin. 

The medicines which I have found of the most decided value in 
albuminuria are muriate of gold and sodium, turpentine, cantharis, 
euonymin, helonias, oil of sandal- wood, corrosive mercury, copaiva, 
and chlorate of potassium. I have never seen such notable effects 
from the muriate of iron, or the ethereal tincture of the perchloride, 
as have been claimed by some observers. 

Lauder Brunton (" Pharmacology and Therapeutics ") says tan- 
nin and tannate of soda appear to have a certain power to lessen 
the exudation of albumin through the Malpigian tufts, as Ribbert 
found that when albuminuria was produced artificially in rabbits by 
temporary ligature of the renal artery, both tannin and tannate of 
soda either lessened or prevented the exudation of albumin. Arbu- 
tin, the active principle of uva ursi, appears to be still more effica- 
cious, but requires to be given in larger doses (four grains three or 
four times a day). Millard says he has used tannin and tannate of 
soda in doses of ten to twenty grains three times a day, and " it 
diminishes the dropsy and the amount of albumin." 

The following cases are collected from French homeopathic jour- 
nals : 

Koch's Lymph in Albuminuria. Case 1. — Acute Parenchy- 
matous Nephritis : General dropsy ; scanty, sanguinolent, very albu- 
minous urine (four grains per litre). Apium virus 6th and cantharis 
6th diminish general dropsy and bloody urine disappears, but albumin, 
after diminution, is stationary at one-half gram. The Koch's lymph 
at the sixth attenuation is prescribed. After eight days of the use 
of this remedy, albumin disappeared entirely ; but the patient, a few 
days after, ate, and drank wine, and the albumin reappeared. 

Case 2. — Chronic Interstitial Nephritis : Case of long duration ; 
uraemic vomiting and convulsions, general arterio-sclerosis ; glonoine, 
fuchsine, nux vomica, iodium are taken before the Koch's remedy, 
and stop vomiting and convulsions. Urine, 11-2 litre per day ; albu- 



DISEASES OF THE URINARY SYSTEM. 607 

min, 0.40 gram ; and urea, only six grams per litre. Koch's lymph, 
6th, is given with the milk diet a few days after, urine increases 
(three litres per day) and albumin diminishes (0.25 gram). Later, 
Koch's lymph, 3d, is prescribed with a mixed diet, milk, eggs, pota- 
toes, and ham, and albumin disappears entirely. Two months after, 
no trace of albumin with the usual tests, but a very sensitive one 
reveals some faint traces of albumin, and pale and copious urine 
indicates still the existence of sclerosis of kidney. In fact there is 
a great amelioration, but we must await the result of the case to pro- 
nounce the word " cured." 

Case 3. — A woman, with a cardiac lesion, and a persistent albu- 
minuria, took the Koch's lymph, 6th, and during the use of the rem- 
edy albuminuria disappeared entirely. 

Case 4. — A young lady, after grippal broncho-pneumonia, had a 
persistent albuminuria. Koch's lymph, 6th, cured the albuminuria 
in a few days. 

Case 5. — Count of V., arterio-sclerosis and vascular cardiopathy ; 
albumin from 0.25 gram to one gram per litre. The Koch's rem- 
edy, 6th, suppressed the albumin in four days. A little later the 
patient took some meat, and albumin reappeared to the amount of 
0.50 gram per litre, and finally disappeared a few days later. 

" The experiments on animals and the clinical facts have demon- 
strated that Koch's lymph in subcutaneous injections has an elective 
action on the heart and kidney. The symptoms of endocarditis and 
albuminuria, with or without hematuria, have been noted during life. 
The inflammation of the endocardium and the lesions of acute paren- 
chymatous nephritis have been observed after death. In experiment- 
ing in guinea pigs, sometimes the large white kidney, sometimes the 
small granular kidney, has been found. Incontestibly, Koch's lymph 
has produced on consumptive men and on the healthy animals, endo- 
carditis and nephritis. We are also justified in giving Koch's lymph 
in the treatment of nephritis, according to the law of similars. The 
clinical experiments need to be repeated to demonstrate the curative 
action of the remedy ; but for the present we have a certain number 
of cases where Koch's lymph produced the disappearance of albu- 
min in urine." Dr. Paul Tousset, in " Art Medica," August, 1892. 

The respiratory symptoms may become very distressing. GEdema 
of the glottis may prove fatal to life. Apis mel. has in some cases 



608 THE PRACTICE OF MEDICINE. 

had a magical effect in arresting it. Pilocarpine has been very 
efficacious in some cases when given by the mouth in doses of one- 
twentieth or one-thirtieth of a grain or used hypodermatically. Both 
are equally useful in oedema of the lungs. 

Attacks of dyspnoea at night may be controlled by aurum, glo- 
noine, or amyl nitrite, if due to vaso-motor spasm. If the heart is 
weak this cardiac dyspnoea is best controlled by quebracho (mother 
tincture, ten drops every half -hour), or its alkaloid, aspidospermine 
\l-\ 0th of a grain every half -hour). 

Tlic Gastric Symptoms. — Violent vomiting is best controlled by 
cocaine, bismuth, creosote, arsenite of copper, or chloroform water. 
Severe diarrhoea is often moderated by arsenic, arsenite of copper, 
veratrum, and croton tig. It is not good practice to arrest it sud- 
denly by astringents, and never by opium, for the latter is always 
dangerous in Brio-ht's disease. 

Anaemia should be combatted with vigor, not only by fresh air 
and blood-making food but by medicines. All the preparations of 
iron are useful, the tincture of the muriate being especially beneficial 
in doses ranging from one to twenty drops three times a day. The 
peptonates of iron are valuable. Arseniate of iron is useful, espe- 
cially the Levigo water from Tyrol which contains it, given in doses 
of a teaspoonf ul after meals. If the heart is weak, a combination of 
digitalis, iron, and strychnine has been of more benefit in my hands 
than any single remedy. Compound tablets are now made and sold 
in our pharmacies containing this combination. 

Cardiac Symjrtoms. — As before stated, the arterial tension and 
cardiac thickening sometimes gives way, and dilatation of the heart 
obtains. There is a gallop-rhythm of the heart like the foetal heart ; 
the breath is short, the urine is scanty and highly albuminous, and 
signs of local dropsy appear. In such the treatment of the impending 
cardiac failure must be prompt and thorough. Digitalis is the main 
remedy. Under its use the heart regains its normal rhythm, the con- 
traction becomes slower and stronger, the urine increases in quan- 
tity, and the albumin diminishes. The dose should not be more than 
ten drops, or less than five, every six hours. If for some reason it is 
not well borne, give convallaria or cactus, in the same doses. In a 
few cases, however, I have found that it required twenty to thirty 
drops of the tincture of cactus. The addition of 1-1 00th of a grain 



DISEASES OF THE URINARY SYSTEM. 609 

of strychnine to each dose of the above greatly enhances their cura- 
tive action. 

Dropsy. — When, during the progress of Bright's disease, the 
renal disease becomes so extended as to injure the secreting function 
of the kidneys, local and general dropsy occurs from accumulation 
of water in the system. This is greatly aggravated if there is a grad- 
ual failure of the hypertrophied heart. We rarely find dropsy so 
long as the heart maintains a force equal or above its normal. 

In these conditions we have two classes of medicines to select 
from — the cardiac tonics, and renal stimulants. Some drugs seem 
to possess both qualities. Among the cardiac tonics besides those 
above mentioned, are spartein, the alkaloid of broom ; neirin, the 
alkaloid of oleander ; erythrophleum (casca) ; stigmata maidis (corn- 
silk); adonis vernalis, caffeine, strophanthus, squill, and several others. 
Those who possess my " Lectures on Diseases of the Heart " will find 
in the last edition a full account of the powers of each cardiac drug, 
the dose, and best method of administration. They are not sup- 
posed to have any direct diuretic action, i. e., no direct action on the 
secreting organs of the kidney, as do cantharis, turpentine, and 
others. But some recent experiments show that this belief may be 
an error, for it has been proved that the urine is largely increased 
under their use, when the heart is in a normal state. 

The second class, the renal stimulants, act directly on the inti- 
mate structures of the kidney as irritants. The most prominent of 
these are cantharis, blatta, apis, turpentine, cubebs, copaiva, apocy- 
num cann, eupatorium, collinsonia, juniper, bitartrate of potassium, 
oxydendron, piper methysticum, salicylate of theobromine (diure- 
tin), mercurius dulcis, seclepias cornuti, barosma, eucalyptus, etc. 

Of all these there are a few which my experience and observa- 
tion place as the most important, namely : apis, apocynum, collin- 
sonia, juniper, bitartrate of potassium, diuretin, and mercurius dulcis. 

Apis should be prepared from the stings of the bee direct, trit- 
urated with sugar of milk, or an infusion of the bee in hot water. 
Apocynum from the green root and given in doses of ten or fifteen 
drops every two hours. Were it not for the nausea and vomiting 
caused by this drug and its bitter taste, nearly all cases of cardiac or 
renal dropsy could be dissipated, but some individuals can tolerate it 
but a short time. If the constituent which causes this gastric irri- 



39 



610 THE PRACTICE OF MEDICINE. 

tation could be eliminated, it would make apocynum the most potent 
remedy for dropsy. I have modified this irritant quality somewhat 
by giving it in chloroform water. The decoction recommended in 
my " New Remedies " acts better than the tincture. 

Bitartrate of potassium (cream of tartar) is nearly as potent as 
apocynum, and has the great advantage of being pleasant to the 
taste and non-irritating to the stomach. The dose varies from five 
to sixty grains three times a day, the quantity depending upon the 
age of the patient. It can be given in water flavored with lemon, 
as " lemonade," largely diluted. Mercurius dulcis has in my prac- 
tice removed the most obstinate dropsies due to combined cardiac 
and renal disease, especially when there was jaundice. Sometimes 
the 2x frequently repeated, or the lx at longer intervals, suffice to 
increase the urine enormously ; but in some cases I have seen the 
most brilliant results from doses of two grains of the crude given 
every two or three hours, until copious, thin, and bilious stools were 
caused, when the dose was reduced to one-tenth of a grain every 
two hours, with the result of causing an enormous flow of urine, which 
continued until the general anasarca and local effusions disappeared. 
In a few cases diuretin has caused copious diuresis, with a corre- 
sponding improvement of the heart's action, but its good effects are 
not usually permanent, and it has to be supplemented by digitalis 
and strychnine. The dose is uncertain. At times ten grains of the 
lx trituration, in other cases ten grains of the crude drug, repeated 
every hour, but when its diuretic influence sets in, the flow of urine 
is enormous. Owing to conditions which have not been explained, 
or to the improper selection of the cardiac or renal drug, there will 
occur instances when no agent seems to affect the heart or kidneys 
in a favorable manner. In such cases we are obliged to expel the 
water in the tissue, and cavities of the body through the intestines, 
by means of agents known as hydrogogue cathartics. The best and 
safest of these are certain alkaline salts. The sulphate of mag- 
nesium and bitartrate of potassium are to be preferred. The nitrate 
of potassium is equally potent, but not so safe. They should be 
given in saturated solution, for only in this form do they act on the 
bowels. If given in a weaker solution than Hive per cent their action 
is on the kidneys if they act at all, and if they do not act on the kid- 
neys they increase the amount of water in the blood, and aggravate 



DISEASES OF THE URINARY SYSTEM. 611 

the dropsy. A tablespoonful of the saturated solution of Epsom 
salts (magnesia sulph.), or cream of tartar, bitartrate of potassium, 
should be given every three or four hours. After the second dose 
the hydrogogue action appears and the drug should be repeated until 
the dropsy is relieved. Other hydrogogue cathartics are elaterium, 
hellebore, euphorbia, corolata, and jalap. Elaterin is the most 
potent and the safest. Only in rare cases does it derange the stom- 
ach, and its use can be continued for weeks or months without injury. 
A man under my care, with dilatation of the heart and interstitial 
nephritis, found no other palliative of his dropsy. For several years 
he took one-tenth of a grain of elaterin at night. This dose was fol- 
lowed by eight or ten profuse watery stools before morning, causing 
the general anasarca to disappear. He attended to his business on 
the Board of Trade during the day. 

Hellebore acts only in this manner. It is not primarily diuretic, 
and if of any value in dropsy it should be in those which follow 
exhausting diarrhoeas or cholera. Helleborein acts similarly to digi- 
talin. 

In the early years of my practice I often used an infusion of 
broom, but the discovery of its active principle, sparteine, has given 
us an agent vastly superior. Sparteine is very insoluble, but the 
sulphate is quite soluble and should be used in all cases. The aver- 
age daily dose should not exceed one grain. The lx trituration 
given in one-grain doses every three hours, or five grains of the 2x 
every two hours, is very efficient. 

Dr. Rhode (" Practitioner ") combines sulphate of sparteine with 
digitalis, convallaria, or strophanthus, and found that it acted very 
well. 

This combination of small doses of different diuretics was in 
several cases borne for many weeks with an unchanging favorable 
action. It was repeatedly observed that diuresis set in satisfactorily 
only when sparteine was added. The effect of the internal admin- 
istration of about one-seventh of a grain four or five times daily was 
unmistakable in the course of twenty-four hours ; and especially 
noteworthy was the increase in tension of the arterial system, on 
which followed a rise in the flow of urine. Brachycardia similar to 
that produced by digitalis Rhode has never observed, but rather 
the resumption of a normal cardiac action where frequency has been 



612 THE PRACTICE OF MEDICINE. 

produced by debilitating conditions, such as great loss of albumin 
or in consequence of influenza. From about ninety beats the pulse 
frequency went down with improvement in the quality to seventy, 
and remained at that rate without further slowing. A particular 
advantage of sulphate of sparteine is its ready solubility in water, 
and indifferent behavior to subcutaneous tissue. A large series of 
injections under the skin has been made with a two per cent spar- 
teine solution, and never were any traces of irritation seen or any 
complaints made about painful sensations. The subcutaneous injec- 
tion shows the action upon the pulse in a few minutes. The excre- 
tion of albumin is not simply apparently less, that is from dilution, 
but also through a direct action of the remedy upon the primary 
urinary passages. Pure congestive albuminuria often completely 
disappears along with other oedema ; but Khode observed recently, 
" in a girl ten years of age, with chronic, frequently recurring, slight 
nephritis of some years' standing, that after twenty-four hours' use 
of sparteine the albumen completely disappeared." When a patient 
with dropsy has piles and varicosis, collinsonia is an admirable rem- 
edy. It will slow the weak rapid heart, unload the portal system, 
act as a gentle laxative, and produce diuresis. The dose is five drops 
of the tincture or lx dilution every two hours. 

Eupatorium purpureum is a good diuretic. It is indicated when 
there is a large quantity of uric acid or urates in the scanty and 
high-colored urine. Dose — the same as for collinsonia. 

Oxydendron (sour-wood) has been known for many years by 
physicians in the South as an efficient remedy for dropsy. We have 
not yet sufficient accurate experience with this drug to enable us to 
decide as to its comparative merits in cardiac and renal dropsies. 
The reports unfortunately have not come from physicians capable of 
making an accurate diagnosis. The dose of the tincture is from 
twenty to sixty drops every two hours. 

Vaccinium crassifolium, a trailing plant found in the mountains 
of the Carolinas, has been found very efficient in obstinate dropsies 
evidently caused by Bright's disease. It is best given in infusion, a 
wineglassf ul every two hours. The tincture may be used in one- 
drachm doses. Corn-silk (stigmata maidis) is a valuable remedy. 
It is indicated in weak and dilated hearts, a weak and irregu- 
lar pulse, great irritability of the bladder and urethra, and scanty 



DISEASES OF THE URINARY SYSTEM. 613 

urine, with frequent urging. The best results are obtained from the 
decoction of the silk, gathered when turning brown, but I have used 
the fluid extract in doses of ten to twenty drops every two hours 
with gratifying results. 

Juniperus virginiana, a decoction of the berries, has long been 
used as a diuretic. It largely increases the watery portions of the 
urine. The decoction is an excellent vehicle for the administration 
of the bitartrate of potassium, ten to twenty grains to an ounce of 
the infusion, given every three hours. 

Dr. Millard shows in his work on " Bright's Disease " an unusual 
intuitive understanding, and excellent judgment in his selection of 
remedies for that disease. He admits that many drugs seem to act 
in accordance with the law of similia. 

In his mention of corrosive sublimate he says : " My experience 
has led me to employ, usually, the mild chloride in interstitial nephri- 
tis ; and the corrosive sublimate in croupous nephritis. In some 
cases, without being able to tell why, I have found benefit to be 
derived only from the opposite course. I am accustomed to give the 
former, prepared by combining or triturating one part of the drug 
with ninety-nine parts of sugar of milk, this being an inert vehicle, 
the adult dose being five to ten grains every two or three hours, 
taking care not to give it in doses so as to affect the gums or to 
relax the bowels. Of corrosive sublimate I use a preparation of one 
part of the crude drug to 10,000 of sugar of milk (ten grains would 
contain a thousandth of a grain of the drug), giving eight to ten 
grains at the same intervals as the proto-chloride (calomel). The 
numerous triturations, and tablet triturates, that have recently come 
into use and are kept by leading druggists, as calomel, corrosive 
sublimate, arsenic, etc., greatly simplify the administration of small 
doses. Although the one-hundredth or one-twentieth of a grain of 
corrosive sublimate might be given in chronic nephritis, I believe such 
doses to be unnecessarily, if not dangerously large in acute forms. I 
know that the possible effect of such small doses will be regarded by 
many with incredulity, but their value has been demonstrated too 
frequently for it to be doubtful, and the recognition of the efficacy 
of these doses is inevitable, as it is a matter of simple and assured 
truth. The experience of medical men of acknowledged experience 
and ability is rapidly tending to show that very minute doses of 



614 THE PRACTICE OF MEDICINE. 

medicine accomplish, in numerous conditions, more than ponderous 
or even moderate doses. Particularly is this shown in those cases 
in which the dual action of drugs is manifest, as in the action of cor- 
rosive sublimate upon the kidneys in health and in disease." 

"It is a matter of no slight intei^est to consider that while corro- 
sive sublimate, alone or in conjunction with other remedies, will often 
correct pathological conditions characterized by the secretion of 
albumin, bloody urine, or suppression of urine, the same remedy 
taken in health, in toxic doses, often produces these very conditions. 
I do not propose to descant upon the merits of any theory, still less 
to support any supposed law of cure, but simply to present facts. 
In acute croupous nephritis we have cloudy swelling of the epithelia 
and increased bulkiness, with the development from the epithelia of 
inflammatory and pus corpuscles, and destruction of the epithelia, 
there is plastic exudation and often exudation of blood cells ; the 
corpora Malpighiana become also the seat of inflammation ; and, as 
a result of these, other changes, albuminuria and anuria, ensue. Now 
corrosive sublimate may produce changes very similar to, if not iden- 
tical with, the above. Orfila and Christison show that the kidneys 
are much inflamed after poisoning by this drug, scanty and frequent 
micturation occurring. Taylor Q On Poisons ') gives an account 
of several cases of poisoning by it, in which there was suppression 
of urine for several days. The general symptoms described are such 
as occur in acute croupous nephritis. The fullest accounts I have 
met with of its effects upon the kidneys is given by T. P. Allen 
('Encyl. Mat. Med.') taken from authentic sources. Among the 
effects mentioned may be cited the following : « Blackish albuminous 
urine ; scanty urine ; bloody urine ; anuria for five days ; ischuria. 
Under the microscope the urine presented granular, fatty tubuli in 
large numbers, showing on their surface epithelial cells of the tubuli 
uriniferi ; also in a state of granular fatty degeneration.' " 

Of the chloride of gold, Dr. Millard says : " The chloride of gold 
has proved of great value in chronic interstitial nephritis. Under 
its use I have often known the albumin to diminish and disappear. 
Aside from its astringent properties I can advance no theory of its 
beneficial action except that it may exert an influence through the 
medium of the spinal cord and renal nerves, experience having 
shown it to be a nervous stimulant and tonic of great importance. 



DISEASES OF THE URINARY SYSTEM. 615 

I have found it of great value in affections of the genito-urinary sys- 
tem unaccompanied by inflammation, as in seminal weakness, loss of 
power of the sphincter of the bladder, the various degrees of impo- 
tence, etc. At all events, its usefulness in chronic nephritis has 
sometimes been unmistakable, and it is likely to prove still more use- 
ful if the patient suffer, as is usual, from nervous symptoms, hypo- 
chondriasis, irritability, vertigo, etc. The chloride of gold and sodium 
seems to produce very much the same effect as the chloride of gold 
simply. I administer these remedies in doses of from one-hundredth 
to one-tenth of a grain three or four times daily, or even oftener." 
Bartholow recommends this preparation in Bright's disease when there 
is high arterial tension. Millard's estimate of arsenic is as follows : 
" Arsenic (arsenious acid) is a remedy from which benefit is some- 
times derived in nephritis. That it should produce some effect in 
nephritis is evident from its action upon the kidneys when taken in 
poisonous doses. It then may produce scanty, bloody, and albumin- 
ous urine, and suppression of urine. Virchow's 'Archiv.,' Bd. 
xxxiv., p. 213, contains the account of the case of a boy poisoned by 
arsenic, whose kidneys were found profoundly affected by it. " The 
cortical tubules were opaque and finely granular, and their epithelia 
could not be isolated." 

" According to H. C. Wood, there is, " in arsenical poisoning, a 
widespread fatty degeneration of the tissues," and in another case, 
quoted from Dr. Saikowsky, in Virchow's " Archiv," Bd. xxxiv., p. 
77, the kidneys were fatty, " their tubes choked up with fat glob- 
ules, their epithelia almost completely destroyed." According to Dr. 
S. Weir Mitchell, the anasarca produced by repeated doses of arsenic 
may be preceded or accompanied by the presence of albumin and of 
tube-casts, as in nephritis. Certainly many of the symptoms and 
pathological conditions which are found in the arsenic cachexia are 
reproduced by nephritis. Among these may be enumerated pallor, 
exhaustion, anaemia, anasarca, nausea, thirst, and neuralgic pains in 
various parts of the body. I have found benefit from its use in only 
a few instances ; one, a case which occurred in a young man twenty 
years of age of chronic croupous nephritis, the result of cold, accom- 
panied by nausea and anasarca ; the treatment consisted exclusively 
of Fowler's solution, five drops being given three times daily, and 
the administration of drachm doses of the tincture of cinchona. The 



616 THE PRACTICE OF MEDICINE. 

cure was complete. I have not been willing, however, to rely upon 
it in acute conditions, but have employed it after the subsidence of 
these. Homeopathic practitioners report many cases of its beneficial 
effects ; one noticeably, in the " All. Homeopath. Zeitung/' No. 68, 
p. 158, in which nephritis, consequent upon scarlatina, with ascites, 
hydrothorax, oedema pulmonum, scanty, bloody, and albuminous 
urine, was cured by it." 

Iodide of potassium he believes is only useful in syphilitic cases, 
and in full doses, twenty to sixty grains a day. 

Pilocarpine is useful in doses of one-twentieth to one-fourth of a 
grain, repeated until copious diaphoresis and salivation appears. It 
has been found of great value in dropsy with threatened oedema of 
the lungs and glottis and in ursemic convulsions. " Dr. Horrocks 
('Lancet,' June 13, 1885) gives an account of a case of puerperal 
convulsions from albuminuria occurring in Guy's Hospital, success- 
fully treated by pilocarpine ; the patient being a healthy primipara. 
When seven months pregnant very severe convulsions set in, occur- 
ring every fifteen minutes, and lasting three to ten minutes. Com- 
plete anuria, ice bags, and purgatives were employed ; face, body, 
and legs highly oedematous. The patient having been for a number 
of hours unconscious, the subcutaneous injection of the hydrochlorate 
of pilocarpine was employed three times, the dose varying from one- 
fourth to one-third of a grain. Each was followed by profuse sweat- 
ing ; temperature was lowered, convulsions ceased, and urine secreted, 
at first highly albuminous. The child was born dead. Mother's 
recovery was perfect. No depression occurred from the use of the 
drug, though Dr. Fordyce Barker has found this an objection to it." 

Hydrate of chloral has been found useful in uraemic convulsions. 
The dose is from ten to thirty grains. If it cannot be given by the 
mouth, use it in suppositories. 

In a paper read before the International Congress at Atlantic 
City (1891), Dr. Oscar Hansen presented the following hints respect- 
ing the homeopathic treatment of Bright's disease. "The most 
important remedies," he said, " are : oleum terebinthinum, arsen- 
icum, phosphorus, acidum phosphoricum, calcarea phos., cuprum 
arsenicosum, plumbum, and aurum muriaticum. Of these the symp- 
toms of terebinthina correspond most closely with the acute form, 
viz., small secretion of urine ; the urine dark and bloody ; the micro- 



DISEASES OF THE URINAKY SYSTEM. 617 

scope shows casts and oxalate of lime : the patient is pale, the skin is 
yellowish, and suffering marked. (If there is organic disease of the 
heart, this remedy is contraindicated.) TTatery mucous diarrhoea, 
nausea, vomiting, and thirst. Arsenicum and its combinations are 
recommended when the heart is attacked. The cardiac lesion is 
nearly always aortic. Arsenicum is also an important medicine for 
emphysema pulmonum. Kafka uses chininum arsenicosum when 
arsenicum fails to act. Hansen has tried this, but has failed to 
obtain any beneficial result." 

"Among the preparations of arsenicum, Buchner particularly 
mentions kali arsenicosum, and says that arsenicum and its prepar- 
ations produce Bright's disease after having produced hypertrophy 
of the left heart. TThen they cease with the medicine, the kidney 
disease will stop first, and thereafter the disease of the heart (exper- 
iment with rabbits). The urine contains albumin. Symptoms for 
arsenicum : Emaciation, loss of power, weakening, oedema over the 
whole body, dropsy. The skin dry, parchment-like ; the color pale- 
yellowish, sleepiness, the members icy cold, the pulse feeble, scarcely 
perceptible. Blindness, forgetfulness, fright, particularly in the 
night, with fear of death. Giddiness with mist before the eyes. 
Ardent and inextinguishable thirst. Drinks often, but little. No 
appetite. Vomiting of all that has been taken. Cardialgia, with 
burning pains. Diminution of the quantity of urine. Short, fre- 
quent and anxious breath. Is obliged to sit up on account of asthma. 
Suffocation. Palpitation of the heart with fear. In the urine are 
found fatty and waxy casts. 

" Phosphorus is one of the most important remedies. The urine 
of a phosphorus patient contains pus, mucus, epithelium, and in some 
cases albumin. In a man who died of poisoning by phosphorus, the 
urinary canals were found rilled with casts ; the urine contained albu- 
min and casts ; the specific gravity was high : and there was a smaller 
quantity of chlorides than in the healthy. 

" Buchner says that arsenic operates on the left heart, phosphorus 
on the right. For pneumonia, joined with Bright's disease, phos- 
phorus is the most important. If there are symptoms of oedema of the 
brain, arsenic is the best : when there is atrophy of the brain, phos- 
phorus. Phosphorus is also indicated when Bright's disease is sec- 
ondary to suppuration, particularly caries. If, during Bright's dis- 



618 THE PRACTICE OF MEDICINE. 

ease, diarrhoea occurs without pain, phosphorus may be commended 
as well as china. Among the symptoms of phosphorus in regard to 
Bright's disease, are : Lassitude in the whole body, hands and feet 
icy, sleepiness. The fatigue is greatest in the morning. Heat in 
the body without thirst, particularly in the evening ; indisposed to 
work, giddiness, forgetfulness, heavy headache, particularly in the 
forehead ; oedema of the upper lids, mist before the eyes, complexion 
pale yellowish-gray, sickly, oedema in the face ; want of appetite ; 
pressure and burning in the stomach ; diarrhoea without pain, but 
weakening and light. Frequent passing water in the night, but a 
small quantity at a time. The urine aqueous and light-colored. 
Serous expectoration from the lungs is an important sign for phos- 
phorus ; fear and anxiety. Asthma. (Edema about the ankles. If 
there is a tuberculous base, phosphorus is important ; likewise when 
there is a weakening of the heart." 

With regard to the following remedies, Hansen has no expe- 
rience. Buchner mentions calcarea phosphorica, and arsenicosa. 
They are particularly for persons who have brought the illness on 
themselves by working in water. " Calcarea arsenicosa for the young 
girl with amennorrhcea, and also ferrum and its combinations. Cu- 
prum aceticum operates on the left heart as does arsenic, and can be 
employed in the last stage of Bright's disease, because it produces 
atrophy of the kidneys." 

Aurum muriaticum is particularly useful in Bright's disease 
resulting from long suppurations, or bone diseases and mercurial 
poisonings. 

Digitalis, and particularly digitaline, is recommended by Baehr 
in the later phases of the illness, when there is bronchitis with serous 
expectoration. The symptoms are : Irregular, small, and scarcely 
perceptible pulse ; frequent desire to urinate in small quantities ; 
oedema ; hands and feet cold ; damp perspiration during the night ; 
and fearfulness. 

" In Bright's disease with scarlet fever, the principal remedies 
are : Apis, hellebore, hepar sulphur, and sepia. Apis is good so 
long as the oedema is small ; hellebore as long as there is albumin 
without casts, and sepia likewise. As soon as there are casts, hepar 
sulphur and arsenicum, and if a complication with the lungs is 
joined, phosphorus. Buchner says, that when an epidemic shows a 



DISEASES OF THE URINARY SYSTEM. 619 

tendency to Bright's disease, then arsenic is most important. In 
Blight's disease from renal calculi he recommends bryonia." 

Dr. Hansen gives in the above a brief resume of Buchner's treat- 
ment. But I repeat what I have asserted above that Buchner's 
treatment is misleading and difficult of comprehension. His path- 
ology is antiquated and not up to the present date. Dr. J. H. 
McClelland's article on Bright's disease in Arndt's " System of 
Medicine " is fully abreast of the time. Its pathology is complete. 
He has gathered from our literature all the treatment of any value 
and much that is valueless. The greatest fault to be found with 
Buchner and McClelland is that they do not treat separately of 
*acute and chronic nephritis. 

PYELITIS. 

Definition. — An inflammation of the pelvis of the kidney. It is 
a suppurative inflammation without distension of that cavity. 

Pyonephrosis is the same disease with accumulation of pus with 
distension, as the mechanical result of some obstruction. When the 
inflammation has become chronic there is obstruction of the ureter ; 
the renal pelvis is distended with pus, and the renal substance liqui- 
fied and destroyed ; or the liquid being absorbed, only a chalky or 
putty-like material is left. 

Causes. — Irritation of calculi, tubercle, typhoid fever, pneu- 
monia, scarlet fever, diphtheria, small pox, and other fevers. 

In these infectious fevers, an acute inflammation of the pelvis of 
the kidney may occur, sometimes hemorrhagic in character, more 
frequently diphtheritic. The presence of decomposing urine, follow- 
ing the pressure on the ureter by tumors or bladder disease, is by 
far the most frequent cause of cystitis. In these cases the inflam- 
mation may not be confined to the pelvis, but pass to the kidney, 
causing pyonephrosis. Occasional causes are cancer, hydatids, the 
ova of parasites, and the saccharine urine of diabetes. There are 
certain drugs, like turpentine, cubebs, copaiva, and other renal irri- 
tants, which may cause purulent inflammation. 

Morbid Anatomy. — In the early stages of this disease the mucous 
membrane is turbid, somewhat swollen, and may show ecchymoses. 
The urine in the pelvis is cloudy, and on examination numbers of 
^epitheleal cells are seen. If caused by infectious fevers there is 



6^0 THE PRACTICE OF MEDICINE. 

usually a grayish pseudo-membrane, limited, or covering the whole 
surface of the pelvis. 

The pyelitis consecutive to cystitis is usually bilateral and the 
kidney is apt to be involved — causing acute suppurative nephritis. 

Symptoms. — In mild grades there are few symptoms — merely 
pain in the back, or tenderness on deep pressure on the affected 
side. The urine is turbid, contains a few mucus and pus cells and 
occasionally blood corpuscles. The urine is acid and there may be a 
trace of albumin. Before the condition of pyuria (discharge of pus) 
is established there may be attacks of pain in the affected side, not 
as severe as renal colic, but with rigors, high fever, and sweats. 
Then the urine, which may have been clear, becomes turbid or 
smoky from the presence of blood, and contains large numbers of 
mucus cells. When the pyelitis, whether calculous or tuberculous, 
has become chronic and suppurative, we then have discharge of pus 
in variable amount, sometimes intermittent. When only one kidney 
is involved the ureter may be temporarily blocked, normal urine is 
passed for a time, and then there is a sudden outflow of pent-up pus, 
and the urine becomes purulent. When this retention occurs, careful 
examination may show a tumor on the side affected. The pus has the 
ordinary characteristics, but portions of kidney tissue may be mixed 
with it. Casts from the tubules may sometimes be present. The urine 
is at first acid, and may remain so even when pus exists in large 
quantities, but if it remains any time in the bladder, or if cystitis 
exists, it becomes ammoniacal. Micturition may be very frequent, 
and much irritability of the bladder be present. In suppurative 
pyelitis an intermitent fever is usually present. The chills may 
occur at regular intervals and the case is often mistaken for malaria. 
Ultimately the fever assumes a hectic type. There is more or less 
anaemia, with progressive wasting and general failure of health. 
Secondary abscesses may develop, with the symptoms of pyaemia. 
Tubercular pyelitis may simulate typhoid fever. Physical examina- 
tion shows tenderness of the affected side, and in pyonephritis enor- 
mous swelling of the affected side. 

Nervous symptoms, such as dyspnoea, convulsions, and coma may 
appear — not unlike those in diabetes. 

Diagnosis. — Tuberculous pyelitis can be ascertained by the 
presence of the bacilli in the urine. 



DISEASES OF THE URINARY SYSTEM. 621 

Calculus pyelitis may show the disintegrated stone in the pus, as 
I have observed in several cases. In perinephritic abscess the urine 
may be free from pus. Suppurative pyelitis and cystitis are fre- 
quently confounded. The two conditions may coexist. But the acid 
character of the pus, the less frequent occurrence of ammoniacal 
decomposition, the local signs in one lumbar region, and the absence 
of pain in the bladder, should be sufficient to differentiate the dis- 
ease. 

Prognosis. — Simple catarrhal pyelitis, or those cases appearing 
during fevers usually recover, but when occurring from diphtheria, 
cholera, or tuberculosis the prognosis is grave. Calculus pyelitis 
usually ends favorably if the stone can be dissolved or removed by 
an operation. When it is associated with grave vesical disorders, 
the prognosis is doubtful, generally bad. 

When pyonephrosis develops the dangers are increased ; per- 
foration may occur, or the patient may be worn out with hectic 
fever. 

Treatment. — Simple acute pyelitis should be treated with abso- 
lute rest and warmth in bed, with plenty of bland diluent drinks, 
hot hip-baths, hot-water bottles or poultices to the loins. Alkaline 
waters, such as Vichy and Carlsbad, or similar ones found in this 
country. No " hard " water should be drunk. It has been the cus- 
tom to give warm or cool infusions of slippery elm, marsh-mallows, 
and other mucilaginous beverages in inflammation of the urinary 
passages, but it is not certain if any mucilage ever reaches those 
organs — probably not. But it is certain that infusions of triticum 
repens, corn-silk, galium, and a few others having a sedative action 
on the urinary tract, are of decided value in this disease. 

Before the discharge of pus sets in, cantharis, cannabis, turpen- 
tine, eucalyptus, mitchella, tussilago, plantago, and all the renal irri- 
tants are useful in minute doses, not lower than the 2x, or a weak 
infusion. 

Mercurius seems to have a decided curative influence when given 
in small doses. Mercurius corrosive 6x is the most curative prepa- 
ration. 

As soon as pus appears, or mucus mixed with pus, and the acute 
inflammation subsides, the best remedies are turpentine, juniper, 
sabina, thuja, cubebs, copaiva, sandal-wood, kava kava (piper methis- 



622 THE PRACTICE OF MEDICINE. 

tieum), barosma (buchu), eucalyptus, hepar sulphur, mercurius, 
chimaphila, petroleum, benzoic acid, berberis, pichi, etc. 

Those which have been most useful in my practice are eucalyp- 
tus, oil of sandal-wood, chimaphila, turpentine, and copaiva. I pre- 
fer the lowest dilutions, and in some torpid, chronic cases, small 
doses of the tincture or pure oil. 

In calculus pyelitis I have had good results from thapsi bursa 
pastoris, lycopodium, uvi ursi, epigaea ; and lithium in uric acid cal- 
culi. The lithia waters are also good adjuvants. When the cal- 
culi are composed of lime or phosphate salts the best remedy is the 
boro-citrate of magnesium. In two severe cases it effected a cure, 
given in doses of from three to five grains four times a day. What- 
ever may be the cause of the pyelitis, with or without cystitis, the 
painful irritability of the urinary passages is complained of more 
than any other symptom. For this irritability there are two classes 
of medicines which possess a positive sedative influence, aside from 
their homeopathicity. They are : (1) belladonna and hyoscyamus, 
and their alkaloids, atropine and hyoscyamine. The former should 
be prescribed in doses of one to five drops of the mother tincture or 
lx; atropine and hyoscyamine in doses of two to five grains of the 
3x trituration. (2) Barosma, epigaea, kava kava, corn-silk, triti- 
cum repens, and mitchella. These have the best effect when given 
in decoction (four drachms of the crude substance to a pint of water), 
a wineglassful (two ounces) every two or three hours. The seda- 
tive dose of the tincture ranges from five to ten drops, which should 
be repeated every two or three hours. 



UILEMIA. 

Definition. — A series of manifestations developing during the 
course of Bright's disease, due to the retention within the blood of 
poisonous materials which should be eliminated in the urine or by 
the bowels. These manifestations are chiefly nervous. This condi- 
tion, though usually seen in nephritis, may occur when the ureters 
are obstructed, or when the circulation of the blood in the kidneys 
is impeded. 

There is much dispute as to the nature of the poisons causing 
this condition. It was once supposed that the chief poison . was 



DISEASES OF THE URINARY SYSTEM. 623 

urea, but this has not been fully proven. It has been supposed that 
carbonate of ammonia was the cause. Dr. Grainger Stewart says 
that many cases of uraemia are due to alterations of the circulation 
and of nutrition of the cortical substance of the brain. There may 
be hemorrhages and degenerative changes. Uraemia has occurred 
in the apparently healthy, but a post-mortem examination in such 
cases has disclosed serious renal changes. Diabetic coma is not the 
same as uraemic coma. Smitz, of Berlin, recognizes two causes of 
the former : (1) weakness of the heart's action, brought about by 
the effect of sugar on the muscular fibres of the heart ; and (2) an 
acute self-poisoning, which has been wrongly termed acetonaemia. 

Traube suggested that uraemia, when characterized by coma and 
convulsion was due to localized oedema of the brain, for the uraemia 
may occur when the urine is profuse. 

Symptoms. — French writers divide these into cerebral, dyspnceic, 
and gastro-intestinal. The cerebral manifestations are mania, delu- 
sional insanity, convulsions, coma, local palsies, occipital headache, 
numbness, cramps, etc. 

Uraemic dyspnoea is classified as continuous, paroxysmal, and 
with Cheyne-Stokes breathing. 

Gastro-intestinal manifestations often set in with abruptness. 
Uncontrolable vomiting may occur, which persists until death. 

Dr. Barie describes a special uraemic stomatitis in which the 
mucosa of the lips, gums, and tongue are swollen and erythematous ; 
with salivation, dysphagia, foul tongue, and offensive breath. 

Diagnosis. — Uraemia may be confounded with cerebral lesions, 
hemorrhage, meningitis, and brain tumors. Apoplexy occurring in 
kidney disease, with stiff arteries and sudden loss of consciousness, 
may simulate uraemia. Uraemia may persist for weeks and months, 
the patient lying in a state of torpor and unconsciousness. This 
may be confounded with the coma of infectious fevers and typhoid. 
Uraemia may also be confounded with poisoning by opium or alcohol. 

Treatment. — The old-school treatment to a certain extent is 
rational and valuable. Copious diaphoresis is a valuable means of 
ridding the blood of noxious substances. Purgation in some cases 
is highly beneficial. The use of sulphate of magnesium, bitartrate 
of potassium, elaterium, croton oil, etc., should be used until the 
bowels are thoroughly evacuated. Diuretics are useful. Apocynum, 



624 THE PRACTICE OF MEDICINE. 

hellebore, strophanthus, sparteine, and digitalis are the most valu- 
able. With the diuretics, copious draughts of water should be swal- 
lowed by the patient if possible. If water is not taken there is dan- 
ger of too great concentration of the blood. Extreme hydrogogue 
purging has aggravated the uraemia. Dr. Smitz's suggestion of giv- 
ing castor oil freely has given better results, especially in diabetic 
coma, than any other purgative. He is of the opinion that the poison 
lies in the bowels. With the action of the oil, resulting in copious, 
black, foul stools, recovery takes place. Of eight cases, four treated 
with castor oil recovered ; and four who had no oil died. He gives 
castor oil even if there is diarrhoea. The dose is one-half to one 
ounce repeated every two hours. I have verified its value in several 
cases. Glonoine should be given, if there is great arterial tension, 
until it is reduced. A drop or two of the lc dilution should be 
given every two hours. Pilocarpine, in doses of one-eighth or one- 
fifteenth of a grain, by the mouth or hypodermatically until copious 
sweating occurs, has saved many cases. 

Buchner recommends cuprum when there are convulsions ; arsenic 
when there is oedema of the brain ; phosphorus when there is atrophy 
of the brain, also hydrocyanic acid and nicotine. 

Dr. J. H. McClelland, in Arndt's " Practice," recommends many 
drugs, among them apis, crotalus, zincum, opium, etc.; but in my 
opinion most of them are valueless, because they do not eliminate 
the poisons, or antidote them. No matter how closely a drug may 
imitate the symptoms of uraemia due to Bright's disease or diabetes, 
it will not be a curative remedy. In the toxaemia of faecal retention 
when there is coma, delirium, convulsions, etc., the remedy which 
closely resembles these symptoms will not relieve or remove the 
symptoms. This failure is because they do not remove the source 
of the toxines. But if we clear out the intestinal tube by means of 
thorough evacuants, all the symptoms quickly disappear. 



ACUTE CYSTITIS. 

Acute inflammation of the bladder may be divided into three 
varieties, namely : inflammation of the mucous membrane, of the 
muscular walls, and of the peritoneal coat. 

Inflammation of the mucous membrane may be catarrhal, croup- 



DISEASES OF THE URINARY SYSTEM. 625 

ous, or diphtheritic. In nearly all cases of acute inflammation of 
the mucosa, the inflammation extends to the sub-serous cellular tis- 
sue, and even to the muscular and peritoneal tissue. 

Causes, — The idiopathic form is rare. Rheumatic and gouty 
cystitis is commoner than is supposed. Exposure to cold and damp- 
ness, as where the whole body is suddenly chilled when wet, or sit- 
ting on a cold, damp surface, has been known to cause cystitis. 

It may be caused by an extension of disease from the urethra, 
kidneys, or some pelvic organ. Direct irritation, by instruments, 
chemical injections, external violence, drugs, calculi, and alkaline 
decomposition of the urine may cause cystitis. 

Symptoms. — Coulson (" Diseases of the Bladder ") gives the 
following truthful and graphic definition of acute cystitis : 

" Unless it supervenes on the chronic form, acute inflammation 
of the bladder generally commences in a sudden manner, and runs 
a rapid course. The patient first experiences some pain in the region 
of the bladder ; this is quickly followed by frequent and irresistible 
desire to make water, which is voided at short intervals, and in small 
quantities ; these two symptoms rapidly increase until they acquire 
a most distressing degree of intensity. The pain is first experienced 
above the pubes, and may be dull for a short time ; but it soon 
becomes violent and extends along the urethra, shooting into the 
perineum and down the thighs. Pressure over the pubes or on the 
perineum greatly increases the pain, and if the posterior wall of the 
bladder be examined by introducing the finger into the rectum, it 
will be found that this part of the organ also is extremely sensitive. 
The slightest movement of the body increases the pain ; the patient 
lies with the limbs drawn up, so as to relax the abdominal and pel- 
vic muscles. As the disease advances, the discharge of urine takes 
place very frequently, for the desire to make water becomes more and 
more urgent, there is a sense of heat and burning along the urethra, 
and the pain felt in passing a few drops of urine is often compared 
by the patient to the passing of molten lead. At the early stage, the 
pain subsides after the urine has ceased to flow, but it returns as 
soon as a small quantity of fluid collects in the bladder. The mucous 
membrane, in fact, soon becomes altogether intolerant of the contact 
of the urine ; and the agony thus produced, together with the inces- 
sant and irresistible call to evacuate the organ, are valuable diagnos- 

40 



626 THE PRACTICE OF MEDICINE. 

tic signs of acute inflammation. The irritability of the bladder is 
communicated to the rectum, and tenesmus is, consequently, a fre- 
quent symptom. 

' ' The condition of the urine varies with the stage of the disease ; 
it is at first mucus, then tinged with blood during the height of the 
disease, and, in many cases, purulent towards the end. These con- 
ditions will be subsequently referred to. 

" Whenever the inflammation is severe, and occupies any con- 
siderable portion of the mucous membrane, constitutional symptoms, 
as might be expected, quickly set in. Rigors occur, and symptom- 
atic fever is developed, severe in degree, but often of a nervous 
character and attended by great disturbance of the digestive organs. 
Hence, vomiting frequently occurs, and the patient is a prey to ner- 
vous symptoms of a very distressing nature. After a few days, 
unless the disease be arrested, the local symptoms acquire an extra- 
ordinary degree of severity ; the pain is constant and of a most dis- 
tressing kind, being accompanied by incessant but unavailing efforts 
to empty the bladder ; the urine comes away in drops, and the blad- 
der gradually loses its expulsive power, though aided by violent con- 
traction of the abdominal muscles. A firm, painful tumor may now 
often be felt above the pubes, for retention is succeeding the incon- 
tinence produced by irritation ; the sufferings of the patient, carried 
to their highest pitch, may appear to subside a little ; but this is 
deceptive ; the character of the fever changes ; the countenance 
becomes anxious, and delirium sets in ; there is often hiccough ; the 
pulse becomes weak, irregular, and then intermitting ; the skin is 
covered with a clammy perspiration ; and the patient finally sinks 
about the eighth or tenth day into a state of prostration or absolute 
coma." 

Acute cystitis is a very serious disease, and requires the most 
cautious and judicious treatment, for often, if the patient recovers, 
the results of the inflammation are serious and render life almost 
insupportable. It is very rare that chronic inflammation does not 
follow. 

Treatment. — As soon as we are satisfied that inflammation is 
impending, the patient should be given gelsemium (tincture) and 
cantharis 2x at frequent intervals. As any irritating matter in the 
lower bowel greatly aggravates cystitis, the rectum and colon should 



DISEASES OF THE URINARY SYSTEM. 627 

"be thoroughly emptied by Epsom salts, bitartrate of potassium, or 
a colon douche of warm water. Then the patient should be given a 
hot hip-bath, for ten or fifteen minutes, and hot flax-seed poultices, 
containing aconite or hamamelis, kept constantly applied. Absolute 
rest in the recumbent position is essential. In many cases sitting 
or standing aggravates the pain. The diet should consist of farina- 
ceous gruels or milk mixed in equal proportions with Yichy or selt- 
zer water. These should be taken in limited quantities. If too 
much is taken the quantity of urine is increased, and consequently 
there is more distension of the bladder and more frequent calls to 
urinate. M. Civiale asserts if we could keep the organ in perfect 
rdpose we could soon subdue the inflammation. 

He advises frequent use of the catheter, but, as Coulson observes : 
" This is excellent advice and should be followed whenever symp- 
toms of retention of urine appear ; but the pain and irritation pro 
duced by the passage of any instrument along the urethra is so 
severe that it would be inadvisable to employ the catheter with the 
sole object of keeping the bladder empty." 

The young and inexperienced physician is too prone to use the 
catheter on all occasions, but it is a procedure that is productive of 
more injury than benefit in the great majority of cases. Only when 
the bladder is abnormally distended should it be used, and when 
used it should be lubricated with a three per cent cocaine solution in 
olive oil. 

The medicinal treatment should be guided by the law of similars, 
and the use of necessary palliatives. When the mucous membrane 
is the principal seat of inflammation, those drugs which cause inflam- 
mation of the mucosa are the remedies. The subjective symptoms 
of a drug should not be our only guide. We must know that they 
are capable of causing cystitis. Many drugs have the symptoms of 
cystitis but they are due to the irritant action of the drug on the 
nerves or muscles of the bladder without causing inflammation. The 
two most important remedies are cantharides and turpentine. Nearly 
all the symptoms of any case of cystitis can be found in their path- 
ogeneses. The next in value are copaiva, cubebs, oil of sandal-wood, 
erigeron, pichi, senecio, and other powerful resins or oleo-resins. 
These cause acute mucous cystitis, with mucus and muco-purulent 
discharge from the inflamed membrane. Cantharis and the cyanide 



628 THE PRACTICE OF MEDICINE. 

of mercury cause croupous inflammation, but this form is rarely met 
with, except after scarlet fever. When the muscular coat is inflamed, 
gelsemium, belladonna, hyoscyamus, bryonia, cimicifuga, and vibur- 
num are indicated. Coulson admits that it may be difficult to dis- 
tinguish between inflammation of the mucosa and that of the mus- 
cular coat, but he says : 

" When the muscular coat is chiefly involved it generally happens 
that the power of passing urine does not exist, and the desire to void 
urine is less frequent, as it is not experienced until a good deal of 
urine is accumulated in the bladder, and then comes on in violent 
paroxysms. Neither is there the burning sensations along the urethra 
which is felt when the mucous membrane alone is affected." 

Two of the best palliatives of the agonizing pain in cystitis are 
corn-silk (stigmata maidis) and hydrangea in doses of ten to twenty 
drops of the tincture every hour or two. 

In some cases we are obliged to use a hypodermic injection of mor- 
phine to relieve the terrible pain, or when using a catheter ; canna- 
bis indica, eucalyptus, piper methisticum, pulsatilla, apis, equisetum, 
and aconite are sometime indicated in acute cases. Phenacetin often 
controls the pain and spasm better than any other anodyne. It is 
particularly useful in those cases in which la grippe attacks the blad- 
der and causes, if not actual inflammation, symptoms closely imitat- 
ing it. In some instances it is combined or alternated with salol 
with excellent results. Phenacetin controls the pain, while salol pre- 
vents putrefaction or fermentative changes in the urine. Tablets con- 
taining two and one-half grains of each may be repeated every hour, 
but I have not hesitated to give a full dose of ten or fifteen grains of 
phenacetin in severe cases, repeating it every six hours. 



CHRONIC CYSTITIS (Catarrh of the Bladder). 

Chronic inflammation of the mucous membrane of the bladder 
may arise from an acute attack or come on slowly and insidiously. 

Coulson (' Diseases of the Bladder") gives the best description 
of any author. He says : " This is a frequent disease, and in many 
respects worthy of serious attention. It may arise from a great 
variety of causes, and presents itself in different degrees of inten- 
sity. The disease may succeed acute inflammation of the mucous 



DISEASES OF THE URINARY SYSTEM. 629 

membrane. In such cases it is sometimes accompanied by ulcera- 
tion, and constitutes a dangerous affection ; but, generally speaking, 
the inflammation is subacute or chronic from the commencement, 
and is characterized by an abundant discharge of mucus with the 
urine, whence the term vesical catarrh. The disease is rarely, if 
ever, an independent affection of the mucous membrane. In almost 
every case which comes under the notice of the surgeon, he will, on 
due examination and inquiry, be able to trace the origin of the 
catarrh to some coexisting malady, or to the forced retention of 
urine, such retention being due either to some obstruction to the nat- 
ural flow of urine, or to atony of the coats of the bladder. 

" The most common exciting causes, therefore, are stricture, stone, 
and enlargement of the prostate ; after these come exposure to cold, 
indulgence in ardent spirits, diuretic and irritating remedies such 
as cantharides, violent exercise on horseback, and venereal excesses ; 
the disease also exists as a symptom in connection with many organic 
diseases of the rectum. In cases of injury and diseases of the spine, 
this state of the bladder is by no means infrequent. Men are more 
subject to this complaint than women, and elderly persons more so 
than the young. It would appear to be uncommon in certain coun- 
tries ; while in others it occurs more frequently, and, according to 
some authors, occasionally assumes an epidemic character. The dis- 
ease prevails in this form in Egypt, and is due to the presence of a 
parasite, the Bilharzia haeinatobia. Gouty persons are very subject 
to this affection. The symptoms of the disease may be divided into 
two classes : those which belong to the inflammatory element, and 
those connected with the state of the urine, the chief of which lat- 
ter class is the presence of vesical mucus in superabundant quantity. 
The inflammation itself seldom gives rise to any general symptoms, 
as fever, etc., while the local signs are not very well marked, except 
in old-standing and severe cases, in which the inflammation may 
assume at intervals a subacute character. In many cases the symp- 
toms are mild, and the patient experiences little inconvenience ; there 
is no pain in the region of the bladder ; but the urine is voided more 
frequently than is natural, and the passage of that fluid is accom- 
panied by a sensation of heat which extends along the urethra or 
shooting pain towards the anus, with a sense of weight in the per- 
ineum." 



£30 THE PRACTICE OF MEDICINE. 

" Cases of this character have been observed to terminate in a 
short time, or to assume an intermittent form, especially when asso- 
ciated with hemorrhoids, or certain petechial affections ; but the dura- 
tion of the complaint is uncertain. Old persons mostly retain it as 
long as they live. 

" At other times the disease assumes a serious character and may 
prove fatal, especially in old and weak persons. The obstinacy and 
danger of the complaint mainly depend on the causes which have 
produced the inflammation and upon the extent to which the kidneys 
are involved. 

" In these severer cases the functions of the urinary apparatus 
are seriously impeded. The bladder is never emptied in a complete 
manner. The expulsion of the urine, and particularly of the last 
few ounces, is more or less painful, according to the violence with 
which the abdominal muscles and bladder contract. The sense of 
heat in the bladder and urethra is converted into scalding ; the desire 
to make water becomes more frequent, and is attended by violent 
straining efforts ; and retention sometimes takes place from obstruc- 
tion of the urethra by clots of inspissated mucus. 

" These symptoms are relieved by drawing off the urine with the 
catheter ; but they return as the organ becomes filled with fluid. 
The patient is very restless and uneasy, and complains of thirst ; the 
bowels are irregular, either constipated or relaxed ; there exists pain 
at the extremity of the penis, around the anus, and in the region of 
the loins. Great prostration of strength and wasting of flesh are 
present. The condition of the urine varies with the duration of the 
symptoms and the causes which have produced the disease. In slight 
and recent cases of chronic catarrh the urine is more or less turbid, 
and contains the same cellular elements as are found in the acute 
form, viz., mucus, epithelium, and pus corpuscles, together with an 
amount of albumen corresponding to the quantity of pus. The reac- 
tion of the fluid is acid or feebly alkaline, and, after the urine has 
been standing for some hours, the cellular elements form a more or 
less copious, loose deposit at the bottom of the glass. In more severe 
cases, and as the disease advances, the changes in the urine become 
more manifest, while still in the bladder the urea undergoes conversion 
into carbonate of ammonia ; the urine therefore becomes decidedly 
alkaline in reaction, and emits an ammoniacal and offensive odor. 



DISEASES OF THE URINARY ORGANS. 631 

Various theories have been advanced to explain this metamorphosis 
of the urea. It was formerly supposed that the mucus secreted by 
the inflamed membrane acted as a ferment, but the more recent view 
is that the presence of a peculiar ferment or excitant of putrefac- 
tion (either in the form of organized bodies, such as bacteria, or of a 
non-organized material, such as a particle of putrid matter) is a nec- 
essary condition for the change in question. The fact, alluded to by 
Niemeyer, that the decomposed and altered state of the urine has 
been known to follow the introduction into the bladder of a dirty 
catheter, appears to indicate that something more than vesical mucus 
is required to produce the change. Dr. Owen Eees has suggested 
that alkalinity of the urine may be sometimes due to the secretion 
of an alkaline mucus by the vesical mucous membrane ; but Dr. Rob- 
erts, having had under observation a patient with extroversion of 
the bladder, was not able to satisfy himself that the alkalinity of the 
exposed mucous membrane was not owing to the blood-serum, which 
oozed from the raw surface, rather than to any mucous secretion 
which might be yielded by an inflamed mucous membrane. 

" When the ammoniacal decomposition has fairly set in, other 
changes also take place in the urine. It becomes muddy, and often 
more or less dark from the presence of the granular pigment-matter 
of disintegrated blood-corpuscles ; the purulent deposit becomes more 
copious, and the pus corpuscles cohere into a gelatinous tenacious 
mass, which has occasionally been found so glutinous that on pour- 
ing it from one vessel to another it was drawn out about a foot in 
length without rending. Enormous quantities of this deposit are 
sometimes passed in the course of twenty-four hours, and it con- 
tains, in addition to cellular elements, the ammoniaco-magnesium 
phosphate, phosphate of lime, and bacteria. When there is ulcera- 
tion of the mucous membrane, red blood-corpuscles will also be 
found. When this glutinous deposit comes away in large quan- 
tities, it is discharged with effort and may occasion retention of 
urine. After micturition, the burning sensation in the region of the 
bladder ceases, but gradually returns as the mucus again collects. 
If the secretion be very copious, symptoms of hectic may supervene 
and the patient dies from exhaustion. 

" Chronic cystitis may last for several years, the symptoms vary- 
ing in urgency from time to time. When the urine has become 



632 THE PRACTICE OF MEDICINE. 

decidedly ammoniacal, another cause of irritation is added to those 
which already exist. The acrid fluid irritates the mucous mem- 
brane and induces fresh inflammation ; the purulent secretion be- 
comes augmented and promotes the decomposition. There are, 
therefore, two sources of mischief, each tending to aggravate and 
perpetuate the other, and thus it happens that a case of chronic 
cystitis, if left to itself, invariably goes from bad to worse. Ulcer- 
ation of the mucous membrane is not an infrequent consequence, and 
when that occurs the local symptoms become more marked. When 
the disease is about to terminate in death, the patient usually falls 
into a low febrile state ; the tongue becomes dry and the stomach 
irritable ; prostration increases, and death is ushered in by delirium 
and coma. Various views have obtained from time to time with 
regard to the causation of these symptoms, and some have attributed 
them to the absorption into the blood of the carbonate of ammo- 
nia. Rosenstein, however, found that the injection of this substance 
into the veins of animals always excited violent muscular convul- 
sions, a symptom which, though characteristic of uraemia, is not 
present in the cases under consideration. He attributes the final 
symptoms of this so-called « urinous fever ' to the presence of bac- 
teria in the blood. 

" The morbid appearances found after death are those of chronic 
inflammation. In the commencement, they are usually confined to 
the neck and posterior part of the bladder ; the mucous membrane, 
usually pale, becomes dotted and streaked with blood, which in part 
is contained in dilated blood-vessels, and in part is extravasated. 
These spots are generally black, the blood having lost its normal 
color. As the disease advances, the discoloration becomes deeper 
and more general ; the membrane is thickened, softened, and floccu- 
lent ; it tears readily from the muscular coat, and is found abraded, 
especially in the neighborhood of some large extravasation. The 
surface is covered with a muco-purulent layer, and the contained 
urine is dark-colored, turbid, and strongly ammoniacal. In a few 
cases of old-standing the mucous surface is pale, and its appearance 
would never lead us to infer the existence of inflammation in any 
degree. If the disease has spread along the mucous lining of the 
ureters to the tubular structure of the kidneys, those canals will 
appear filled with a muco-purulent fluid, and the kidneys will pre- 



DISEASES OF THE URINARY SYSTEM. 633 

sent the appearances characteristic of pyelitis. The walls of the 
bladder become thickened from effusion into its cellular tissue ; 
ulceration often takes place in the mucous membrane, which, as in 
acute inflammation, may be entirely removed, leaving exposed the 
hypertrophied muscular fibres. Ulceration, however, is more fre- 
quently observed whenever, from some occasional cause, the inflam- 
mation assumes an acute character. Perforation of the bladder, 
with suppurative peritonitis, may be found as a cou sequence of the 
ulceration. The most prominent portions of these muscular col- 
umns are usually of a bluish-red or purplish color ; while between 
them, the membrane is pale, swollen, soft, and offers little resist- 
ance ; occasionally small ulcerations are found. But what is very 
remarkable, between the hypertrophied columns, pouches or sacs 
generally coexist with dilated ureters, both states being produced by 
the same physical cause. These pouches often contain calculous con- 
cretions." 

" In extreme cases of this kind, the secreting structure of the 
kidney becomes reduced to a thin layer, covering the widely dilated 
pelvis and infundibula. The ureters, in such instances, are both 
dilated and tortuous, and the lining membrane is rough and granu- 
lar, and in some instances is covered by flakes of lymph. 

" In cases where the obstacle to the escape of urine has existed 
for a considerable period the walls of the bladder, and particularly 
the muscular coat, will be found enormously hypertrophied, and 
such hypertrophy may be either concentric or eccentric. In the 
former case the capacity of the organ may be much diminished, but 
in eccentric hypertrophy, which is much more common, the bladder 
may be so much dilated as to contain several pints of urine and to 
reach as high as the umbilicus. In addition to the morbid appear- 
ances presented by the bladder itself, those of the various conditions 
upon which the disease depends will also be found. Among those 
may be mentioned strictures of the urethra, prostatic enlargement, 
calculi, etc. 

"It has been said that when the vesical mucus is passed in small 
quantity, the disorder may be mistaken for an involuntary discharge of 
semen, which accompanies in some persons the escape of the urine and 
fasces. These two fluids are somewhat analogous in their appearance, 
but may easily be distinguished by the aid of the microscope. The urine 



634 THE PRACTICE OF MEDICINE. 

in this disorder may also be distinguished from chylous urine, because 
the latter, immediately it is passed, presents a whitish milky appear- 
ance or opaline tint, due to the presence of fatty matter which forms 
a creamy layer on the surface after the urine has stood for some 
hours ; on the contrary, the urine in vesical catarrh is at first turbid ; 
on standing the sediment becomes viscid, ropy, and flocculent, or 
united into one clot." 

" Chronic inflammation of the bladder connected with disease of 
the prostate or even with lesions seated about the neck of the organ, 
is always more severe and difficult of cure than when dependent on 
stricture of the urethra. The difference between the exciting causes 
readily accounts for this difference in the affection which they pro- 
duce. It is slow and insidious in its progress, and is liable to vary 
much in intensity at different periods of the disease. A careful 
examination of the bladder will alone enable the surgeon to ascer- 
tain the particular nature of the coexisting lesion, and determine 
the method of treatment required for it." 

Treatment. — The diet in catarrh of the bladder should consist 
of those foods which do not impart irritant quantities to the urine 
or increase its acidity, if too acid, which is rare, or increase its 
alkalinity. Extreme alkalinity is the rule. After removing any 
mechanical cause which may exist, we must select medicinal reme- 
dies which, when taken to excess, will cause a similar condition. 
This is an axiom that no school can dispute ; for all advise in the 
strongest language the very drugs which will cause cystitis, acute 
and chronic, e. g., Coulson advises copaiva, cubebs, buchu, and tur- 
pentine. 

Sir Astley Cooper says : " The best remedy that can possibly be 
taken is the balsam of copaiva : no medicine so completely robs the 
urine of its mucus as this." He might have added that no medi- 
cine so certainly causes acute and chronic catarrh of the bladder. 
His dose is moderate, " eight or ten drops three times a day." 

The oleo-resins, then, are the chief remedies for this disorder. 
When taken into the circulation they are eliminated through the 
kidneys, and it is their actual contact with the diseased mucous sur- 
faces which cures the morbid condition. In fact, it is my opinion 
that all drugs which cause and cure catarrhal diseases act in this 
manner, and not by any supposed dynamic influence through the 



DISEASES OF THE URINARY SYSTEM. 635 

nerves. Medicines which cause and cure painful affections of the 
bladder may, however, act through the nerves which supply that 
viscus. The chief remedies for catarrh of the bladder are abies, 
buchu, cantharis, cannabis, cubebs, chimaphila, erigeron, eucalyptus, 
corn-silk, kava kava, populus, pulsatilla, grindelia, pinus canadensis, 
thuja, turpentine, uva ursi, baldo, pichi, salol, and phenacetin. 

Of these, my experience has been mainly with buchu, chimaphila, 
eucalyptus, cubebs, kava kava, corn-silk, turpentine, and pichi. As 
a rule I give one of these in alternation or combination with some 
medicine indicated for the pain. If cubebs is indicated by the tena- 
cious, stringy mucus, and hyoscyamus by the spasmodic pain, I pre- 
scribe them together. No medicine has been so serviceable for me 
in cases remarkable for the great amount of muco-purulent dis- 
charge, and the absence of pain, as chimaphila. Such cases occur 
principally in women. I have cured cases where the mucus sediment 
was fifty per cent. The drug was given in the fluid extract (which 
is better than the tincture), fifteen to twenty drops every three or 
four hours. 

Eucalyptus is a splendid remedy. The urine is scanty and foul- 
smelling, and the muco-purulent sediment large. There is burning 
when urinating, with fever and general malaise. It is even useful 
when there is "urinary fever " (which is really a septicaemia), with 
chills in the afternoon, hectic and night sweats. 

Copaiva is most suitable when the disease is consequent on a gon- 
orrhoea. The mucous is yellow and creamy and there is much ves- 
ical tenesmus. Thuja also for similar conditions, and especially 
when the prostate is enlarged. If these two last medicines fail, try 
kava (piper methisticum), which has been found very useful in such 
cases. Uva ursi is indicated when there is a great inertia of the 
bladder and it fails to expel all the mucus. It is said to act on the 
bladder as ergot does on the uterus. (Nux vomica acts similarly on 
the bladder.) 

Salol is a medicine of the greatest importance. It is a sedative to 
the mucous surface, disinfectant to the contents of the bladder, and 
curative to the catarrhal process perhaps more promptly than any 
other drug. It can be alternated with corn-silk, hydrangea, phena- 
cetin, or belladonna, if the pain is intense and the bladder very irri- 
table. 



636 THE PRACTICE OF MEDICINE. 

The antisepsis of the renal passages by the use of salol in the 
intestinal tube is a method of decided value. As a consequence of 
the action of the pancreatic juice, salol splits up into carbolic and 
salicylic acids, which are then eliminated by the kidneys, carbolic 
acid being unchanged salicylic acid after it has combined with sodium. 
Investigations by Nencki, Sahli, and Lepine have proved the truth 
of this statement beyond contradiction, and these writers have as 
a consequence, recommended its use for " internal disinfection " in 
cholera, typhoid fever, and other bacterial diseases. Dr. Dreyfuss 
(" Wiener Medicinische Blsetter," December 19, 1889), bearing these 
facts in mind, has recommended its use internally as a means of 
inducing the passage of an antiseptic fluid through the kidneys, ure- 
ters, bladder, and urethra, and claims that it acts in a much more 
intensive manner and covers a wider field than can be accomplished 
through the injection of antiseptic fluid. Sahli has further shown 
that the urine of patients who have taken salol internally is aseptic, 
and that salol in large doses is well borne and never produces toxic 
symptoms. It is, therefore, quite as suitable for producing antisepsis in 
the urinary passages as naphthol is for the antisepsis of the intestinal 
tract. Dreyfuss has employed salol, either alone or in composition 
with various balsamics, in blennorrhoea, the full dose varying from 
seventy-five to one hundred and twenty grains. Even in acute cases, 
treated at the very outset, this method rapidly diminished the secre- 
tion, and in some few cases arrested it within a few days. Its effects 
are especially marked in combination with the use of cubebs or 
copaiva. 

Finally, Dreyfuss recommends this use of salol in operations upon 
the urinary organs, for in this way the urine is kept aseptic, and one 
source of danger is thus avoided. Another valuable property which 
salol possesses is an anodyne or sedative action on the mucous mem- 
brane of the urinary passages, about equalling corn-silk or triticum 
repens. 

Dr. Strizower, an eminent German physician, says that, " With 
the aid of sodium salicylate and salol he has been able to hasten the 
discharge of gall-stones and to obviate their development. He has 
stopped prescribing Carlsbad water ; and since the anodyne effect of 
antipyrine became known, he has also discontinued using morphine in 
cholelithiasis. He administers 0.6 grammes (ten grains) of antipyrine 



DISEASES OF THE URINARY SYSTEM. 637 

at the beginning of the attack of colie, and the same quantity of salol 
or sodium salicylate three to four times daily in the intervals between 
the colic attacks. This is said to suffice for breaking up an attack. 
The patients complain no longer of the heaviness in the entire body 
and the depression usually observed after morphine injections; the 
attacks become less frequent, and finally stay away permanently. 

If the catarrhal cystitis is complicated with uric acid gravel, epi- 
gea, piperazin, lycopodium, mitchella, hydrangea, and lithium should 
be given with the catarrhal remedy. 

Turpentine is especially indicated when the urine is bloody. 
Venice and Chian turpentine have been recommended by Dupy- 
tren and Coulson. Turpene hydrate has both caused and cured 
many cases. When the urine is very alkaline the mineral acids are 
useful, while the vegetable acids in fruits are to be avoided. 

The tincture of the perchloride of iron has been of great service 
in my hands for the diseases resulting from anaemia. Coulson recom- 
mends alchemilla arvensis when there is a large amount of phos- 
phates with the mucus. English writers all recommend pareira 
brava, combined with nitro-muriatic acid, in typical cases, when the 
mucus deposit is large, and the bladder irritable. 

In cases with a concomitant eczema of the skin I have seen good 
results from sulphur, graphites, and iodide of arsenic. 

Local Medications. — The bladder, when affected by chronic 
inflammation, is susceptible of being acted on directly by various 
remedies introduced through the urethra. It rarely happens that 
patients suffering from chronic cystitis are able to empty the blad- 
der completely ; after each effort a certain quantity of urine always 
remains behind and undergoes decomposition, and thus adds to the 
irritation. Even the regular use of the catheter fails to remedy 
this. But if an elastic catheter be introduced and the urine drawn, 
and then a small quantity (not more than two ounces) of water at a 
temperature of 100° injected (by means of an india rubber bag, hav- 
ing a stop-cock and a tapering nozzle to fit the urethra), after a short 
interval the water will escape of itself. This operation should be 
repeated several times, until the water comes away tolerably clear, 
when it may be concluded that the bladder has been thoroughly 
washed out. The water should be introduced gently and slowly, so 
as not to cause rapid distension of the bladder. The operation should 



638 THE PRACTICE OF MEDICINE. 

be repeated every day or oftener if the last portion of the urine con- 
tinues to contain mucus. The best disinfecting injections are sali- 
cylate of sodium (two per cent), saccharin (one to one thousand), 
eucalyptus water, boric acid (one per cent), balsam of copaiva. (One 
to two ounces of barley water is recommended by Dr. Devergie.) 

Saccharin internally by the mouth, one grain to four ounces of 
water, has been found useful ; also five grains of boric acid to four 
ounces of water. Both can be given every three hours. 

If we desire to get the curative action of a drug on the mucous 
surfaces, one of the best injections is a solution of colorless hydras- 
tine, one drachm to two ounces of water. A two per cent solution of 
resorcin is an excellent injection ; very weak solution of perman- 
ganate of potassium, creoline, thymol, lysol, or pyoctanin may be 
tried. 

In no disease is it more important that the clothing should be 
warm ; all wool next the skin, even in summer, should be worn. The 
feet should be kept warm and dry. Sudden changes of temperature 
should be guarded against. A milk diet is often required, and but- 
termilk or koumiss is often better than milk. 



VESICAL DISORDERS OF WOMAN. 

It appears to me necessary that a special section should be devoted 
to the diseases of the bladder in women. In many respects they dif- 
fer from the bladder affections of men. Owing to certain physical 
peculiarities, such as the shortness and large bore of the female 
urethra, and the anatomical relations of the bladder to the pelvic 
organs, vesical diseases in the female vary considerably from those 
of the male, and therefore need separate mention. Cystitis, or 
catarrh of the bladder, is far more frequent in women than in men ; 
but on the other hand, on account of the absence of the prostate 
gland, and on account of the short and capacious urethra, the former 
are as a rule less profoundly affected by it. 

Vesical troubles in women may arise from the same causes as 
those in men, such as urinary calculus, gonorrhoea, acrid urine, a 
chill, etc., but the most common source, beyond all question, is some 
uterine disorder affecting the bladder, either directly or through 



DISEASES OF THE URINARY ORGANS. 639 

reflex action or irritation. The next cause in order of frequency 
is hysteria, which will imitate nearly every disease of the blad- 
der, and especially those neuroses of the prostate in men which I 
have described in previous pages. Some of the very worst and 
most painful and obstinate cases of vesical hysteria which have 
come under my care have been in women of middle age, recently 
married, and probably due to excessive irritation. No ordinary 
remedy, no matter how closely affiliated, appeared to give relief. 
Large doses of the bromides, morphine, and hyoscyamus had some 
palliative effect, but a cure was mainly brought about by hot hip- 
baths, local application of cocaine, and nightly doses of chloral to 
induce sleep. 

Vesical irritation of a painful and annoying character may arise 
from anteversion and retroversion of the womb, also from uterine 
or ovarian tumors. It may be caused by stone in the bladder, by 
rectal irritation, or a gravid uterus. It is easy to relieve vesical 
irritation from uterine displacement by the use of a pessary, or by 
the abdominal bandage when from abdominal tumors, or during preg- 
nancy. If the rectum is at fault try anodyne suppositories, or a 
final resort to Pratt's or Allingham's operations. 

The vesical troubles of school-girls arise from two causes : (1) 
Neglect of the call of nature, allowing the bladder to fill until the 
walls are over-distended, with consequent paralysis or spasm ; and 
(2) nervous exhaustion from " cramming," and excessive study. 
The quickest way to cure these cases is removal from the school to 
a purer air and an out-of-door life, and regularity in attending to 
the functions of the bladder and bowels. The best medicinal rem- 
edies are belladonna and mono-bromide of camphor. 

Many cases of irritable bladder in women can be cured only by 
dilatation of urethra, even to the extent of causing temporary par- 
alysis and incontinence of urine. 

A paper on irritable bladder and frequent micturition in females 
has lately been published by Dr. Alexander Duke, ex- Assistant Mas- 
ter, Rotunda Hospital, Dublin. " In cases where we are able to 
exclude the urine itself as a source of irritation, as well as uterine 
disorders, we are obliged to seek for some other cause. In a great 
number of these cases there will be found an unnatural appear- 
ance of the meatus urinarius, the opening being much smaller and 



640 THE PRACTICE OF MEDICINE. 

rounder, reminding one somewhat of the pin-hole seen in conjunc- 
tion with conical cervix uteri. This description of case is compara- 
tively easily cured by forcible dilatation of the meatus or urethral 
canal." Dr. Duke has noticed a rather curious phenomenon to occur 
during the process, that is, the escape of a considerable quantity of. 
urine when the blades of the dilator are freely opened (and this after 
the bladder has been but a few minutes before fully emptied to all 
appearances by the catheter), the amount of urine escaping being 
fully equal in some cases to that previously removed. It has always 
been a puzzle to him where this urine came from, as the diagnosis 
of cystocele is a comparatively easy one, and a sacculated condition 
of the bladder could not possibly exist in all cases in which he has 
noticed this peculiarity. Dilatation of the urethral canal is the most 
useful treatment in all cases when the urine i& normal, and spasm 
and irritability is complained of. If there is a manifest want of 
tone in the bladder, Dr. Duke recommends tincture ferri muriati, 
^antharides, and nux vomica, which has always given him satisfac- 
tory results. The galvanic battery is a dernier resort, and gives 
most satisfactory results in some apparently hopeless cases, one lady 
patient having worn a urinal for more than five years, night and 
day, previous to its employment. 

Very obstinate, too, is the irritable urethra of women who have 
had a severe confinement, wherein the neck of the bladder has suf- 
fered from prolonged pressure and the catheter has been used. In 
these cases cystitis rarely develops unless the catheter is dirty, but 
a condition of irritability obtains which rivals the hysterical bladder 
and requires the same heroic treatment. In ordinary cases of ner- 
vous irritability of the bladder, such medicines as cantharis, hyoscya- 
mus, cannabis, buchu, epigea, corn-silk, mitchella, galium, and trit- 
icum, will remove it. If chronic cystitis is present recourse must be 
had to injections into the bladder. Boric acid, white hydrastis, per- 
oxide of hydrogen, and eucalyptus have given the best results. 

Dr. Katherine Miller, in a recent paper on " Enuresis in Girls," 
says : 

" More common even than enuresis among girls is a form of irri- 
tability of the bladder, manifesting itself chiefly in an inability to 
retain the urine in the normal manner. It is often complained of 
in school-girls, who are obliged to leave the school-room, even between 



DISEASES OF THE URINARY SYSTEM. 641 

intermission, in order to pass the urine, else the bladder, spasmodic- 
ally contracting, empties itself in spite of every effort of restraint. 
Even with the promptest attention to its demands, these girls are 
occasionally subjected to the mortification of wetting their clothing. 
Oftentimes no complaint is made of any other symptoms than this 
annoying vesical irritability. The condition is more common at the 
age of six to twelve or fourteen, but may, if untreated, persist indefi- 
nitely. Examination reveals an extremely sensitive and hyperaemic 
condition about the vaginal orifice, and further investigations will 
show the extension of this tenderness within the vagina. Often this 
latter investigation can only be made by the use of an anaesthetic, 
not only because of the small size of the parts, but because of their 
extreme sensitiveness. Whatever the cause, the treatment must be 
directed to the removal of the vaginitis, when the bladder will recover 
its tone. 

" Cleanliness must be enjoined. Not only is careful washing 
needful, but warm hip-baths are of value. Soothing powders must be 
dusted on, the vulva being opened as far as possible, and children 
old enough to under staud the aims of the procedure will generally 
submit to the application, at night, of a small plegget of absorbent 
cotton, wet with a healing lotion containing pinus canadensis, hama- 
melis, carbolic acid, or similar remedy, diluted with thin boiled starch. 
Where the urine is normal, rhus aromatica has proved a valuable 
aid in controlling the habit of irritability of the bladder and reliev- 
ing the symptoms, till the cause can be removed." 

In similar cases I have found the new remedy, pichi, to be inval- 
uable. In doses of a few drops of the lx or 3x in young children, 
conjoined with local applications of calendula and boric acid, it has 
given prompt relief. Erigeron canadensis has been found useful. 

It must not be forgotten that in young female children, vesical 
irritability of a severe character has been known to be caused by the 
migration of ascarides into the vagina, and even into the urethra. 

Vascular tumors of the meatus are a prominent cause of in- 
tense dysuria. Few diseases of such trifling size occasion more dis- 
tress than these vascular excrescences. They vary in size from a 
pin's head to a strawberry. They grow from around and on the 
margin of the meatus, and I have often seen them growing half an 
inch within the external orifice. They are exquisitely sensitive, and 

41 



642 THE PRACTICE OF MEDICINE. 

the slightest touch with a brush, or the passage of urine, causes 
intense suffering, locally, and a great many distressing reflex symp- 
toms. No internal remedy has the slightest effect. The treatment 
must be topical. If pedunculated they can be removed with a liga- 
ture, but as they seem to grow again from their base, it should be 
cauterized by chromic acid, fifty per cent, which is the surest, or car- 
bolic or nitric acid. If the ligature cannot be used I prefer to remove 
them with a pair of curved scissors, taking care to remove with the 
excrescence a portion of the mucous membrane from which it grows 
— a fine pair of forceps being used to seize and elevate the excres- 
cence. The actual or galvanic cautery is preferred by some. If 
very small, touching with chromic acid is sufficient. Before oper- 
ating the surface should be painted with cocaine solution, twenty 
per cent, until all local sensibility is destroyed or greatly blunted. 

Fissure of the urethra causes as much distress and disturbance 
as fissure of the anus. Munde says the latter has caused decided 
symptoms of cystitis. Fissures at the neck of the bladder is a pain- 
ful affection, but difficult of diagnosis from cystitis, unless he ure- 
thra is dilated and the surface viewed with a uroscope. 

Dilatation, until the base of the fissure is deepened, has been 
known to cure all forms of fissure. Some women are troubled with 
involuntary spurting out of urine when coughing, laughing, lifting, 
or reaching up. This is due to a weakness of the sphincter vesicae, 
and can be removed by causticum, gelsemium, belladonna, or hyos- 
cyamus 3x, or nux vomica, ergot, or ustilago tincture. Cantharides 
will cure a majority of such cases, given in doses of a drop or two of 
the lx dilution three times a day. 



IRRITABLE BLADDER AND URETHRA. 

Under this name are arrayed several conditions of the neck of the 
bladder and the prostatic sinus around the seminal ducts. French 
writers call it neuralgia of the vesicle neck, but their word " neural- 
gia " does not mean pain as it does in English. They refer to the 
hyperesthesia of the deep urethra and neck of the bladder. The 
causes, according to Keyes, are numerous, " but none holds the same 
prominence as does the perversion of the sexual instinct and appetite, 
its over-stimulation by excess, or more often its imperfect satisfac- 



DISEASES OF THE URINARY SYSTEM. 643 

tion." " The action of these causes," he says, " is to congest and 
keep in a more or less constant irritation the prostatic sinus in the 
neighborhood of the seminal ducts. This congestion extends readily 
in both directions, involving the cut-off muscles in front, and creep- 
ing backward into the neck of the bladder through the inner orifice 
of the urethra." Beard describes this condition under the name of 
"irritable urethra." Next to this sexual cause in producing neu- 
ralgia of the vesicle neck, Keyes places the arthritic and gouty dia- 
thesis attended by acidity and concentration of the secretions, espe- 
cially the urine. Other causes are strictures, enlarged prostate, cal- 
culi, worms, hemorrhoids, fissure of the rectum, etc. Pratt, in his 
" Orificial Surgery," dwells upon this disease, which he believes to be 
produced by disorders of the urethra and rectum. 

Symptoms. — The symptoms of a typical case are, according to 
Keyes, " Frequent desire to urinate, the attack coming on sometimes 
suddenly, sometimes gradually, without appreciable causes, or per- 
haps commencing in an inflammatory condition of the parts (gon- 
orrhoea), but not subsiding with the latter. This desire to empty 
the bladder may or may not be attended by a slight burning pain 
in the act. In severe cases there is powerful tenesmus (cramp). 
The relief after urination is usually not perfect, and the desire soon 
returns. There is often a certain slowness in the act, the bladder 
contracting without force, and the stream being small, or, on the 
other hand, the bladder may contract spasmodically when the call 
comes, throwing out the urine with great force. Again, there may 
be spasmodic contraction of the cut-off muscles, leading to inability 
to urinate, or hesitation in the act." 

"There are some prominent peculiarities about these calls to 
urinate. They rarely disturb the patient at night. Once asleep, 
he rests quietly, but if, from anxiety or other causes, he is restless 
and wakeful, he is obliged to empty his bladder frequently, by night 
as well as by day. When under the stimulation of liquor, the urine 
can sometimes be held for a number of hours. When pleasantly 
occupied, or deeply interested in anything, as at the theatre, in 
agreeable company, or engaged at some earnest work, the bladder is 
often but little, if at all, troublesome. On rainy, damp, or cold 
days, the calls to urinate are more frequent, perhaps once an hour. 
The same occurs during illness, and especially during mental worry 



644 THE PRACTICE OF MEDICINE. 

or disquietude. The spirits are usually depressed, the patient anx- 
ious, perhaps hypochondriacal. The urine is usually clear, rarely 
shows any purulent deposit (unless the affection has lasted for months 
or years), but often contains an excess of amorphous phosphates. 
This deposit sometimes alternates from week to week with a deposit 
of urates. Sometimes both ingredients exist in excess. Crystals of 
oxalate of lime are not uncommonly present. There is no soreness 
over the pubes, though pressure there will sometimes call forth a 
desire to urinate. In the rectum there is often a slight sensation of 
heat and uneasiness. There is frequently a dull, dragging, uncom- 
fortable feeling in the perineum, but pressure there is not painful. 
Erections may be frequent or absent — the latter to such an extent 
that the patient may believe himself impotent. There may be abnor- 
mal feelings of heat and tenderness about the scrotum and testes. 
Added to these, there may be all sorts of functional disturbances of 
the bowels, often constipation, with feeling of lassitude and a general 
weakness. Spasmodic stricture of the urethra may come on as an ac- 
companiment of this condition, while great irritability of the cut-off 
muscles exists as a rule. Nocturnal emissions are not infrequent. " 
The diagnosis of this condition from organic diseases of the blad- 
der is best described by Keyes, who relies mainly on the results of a 
physical examination. He says : " On exploring the urethra with a 
full-sized blunt steel sound in these cases, it is customary to find 
the whole canal sensitive and irritable. The muscular fibres con- 
tract about the instrument, and oppose its progress. At the mem- 
braneous urethra, the cut-off muscles contract spasmodically, often 
sufficiently to bar the progress of the sound entirely, and give the 
idea of organic stricture. As the instrument advances, the cut-off 
muscles may be felt to quiver in slight partial contractions, while 
the patient complains greatly of pain. When the beak of the sound 
enters the prostatic sinus, the patient is very apt to feel faint. He 
may indeed go into syncope, or have an attack of nausea ; or, per- 
haps, a sexual orgasm may be induced, in which case the prostate 
and cut-off muscles contract violently on the sound, causing the 
patient considerable pain. As the sound passes the neck of the 
bladder, either the natural feeling of a desire to urinate will not be 
perceived or (usually) the sensation will be highly exaggerated and 
painful. Sometimes spasms of the bladder will be induced and the 



DISEASES OF THE URINARY SYSTEM. 645 

instrument will be forced out, or a jet of urine may gush out along 
the urethra outside of the instrument. On withdrawing the sound, 
a little blood will often be found upon the beak, but the patient as a 
rule feels relieved, and will often experience for hours thereafter an 
ease and local comfort such as he has been a stranger to for months, 
perhaps for years ; his interval for urination being decidedly length- 
ened, although the smarting at the next urinary act will be greater 
than before. The above general outline of symptoms will include 
most cases of pure neuralgias of the vesical neck, where there is no 
lesion, and has been no serious antecedent disease." 

Treatment. — The moral and hygienic treatment are most import- 
ant. If the patient is single he should get married. No clandes- 
tine sexual intimacy can approach the curative influence of a mar- 
riage based on love or respect. If this is not feasible the mind should 
be directed into quiet paths of study, work, or out-of-door life free 
from excitement of any kind affecting the sexual life. Alcohol and 
tobacco in excess should be avoided. These rules will place the 
patient in a curable condition if they do not cure. If the urine is 
acid it should be made alkaline ; mineral acids should be given if 
the urine is alkaline or phosphatic. 

There are certain medicines which physiologically act as sedatives 
to the bladder, deep urethra, and seminal vesicles. The most potent 
are corn-silk, hyoscyamus, epigaea, triticum, galium, buchu, salix 
niger, monobromide of camphor, ferro-cyanide of potassium, sali- 
cylate of sodium, salol, plantago, and rhus aromatica. These should 
be used in small but material doses of the tincture or lx trituration. 
Equally important are a class of medicines capable of causing a sim- 
ilar condition. The most typical are cantharis, phosphorus, nux 
vomica, aurum, and equisetum. But the whole range of vesical irri- 
tants should be consulted and the remedy selected by the totality of 
the local and general symptoms of the patient, and given in the small- 
est doses that will act on the organism. 

Keyes and Pratt are emphatic in their praises of the steel sound. 
They declare that nothing is so potent in a pure case where the ner- 
vous element is predominant. It should be well warmed and oiled 
and introduced with the utmost gentleness. The time for a reintro- 
duction will depend upon the duration of the effect of a single use of 
the instrument. 



646 THE PRACTICE OF MEDICINE. 

"If there is prostatitis or cystitis the instrument will aggravate 
the local condition ; if neuralgia, its gentle use will always be fol- 
lowed by comfort, and the relief will last a variable time. In old 
subjects it is sometimes necessary at first to reintroduce the instru- 
ment every day, in younger subjects, every second, third, or fourth 
day. The action of the sound seems to be to blunt the morbid sen- 
sibility of the parts by pressure, to improve the circulation by tem- 
porarily squeezing out the blood, and by putting the irritated mus- 
cles slightly on the stretch." (Keyes.) 

A common cause of irritability of the bladder and urethra is cath- 
eterization. A patient who has never had the slightest irritability is 
catheterized for a retention, from a cold or spasm of the urethra, 
or after confinement. Sometimes one introduction of the catheter 
is sufficient to set up an irritability that will last for weeks and 
months. We are often in too great a hurry to relieve patients from 
temporary retention. 

The properly selected remedy (cantharis, hyoscyamus, gelsemium, 
or apis) will generally relieve the retention. I would not advise 
waiting more than twelve or eighteen hours, but I do protest against 
resorting to the catheter too soon, or using it too often. Two or 
three times a day is sufficient. 

The treatment of irritable bladder and urethra from this cause 
consists in using the soft velvet catheter in preference to others, 
using sterilized olive oil, and in some cases the one per cent solution 
of cocaine in the oil. The medicines indicated are arnica if the 
catheter has bruised the tract, or if the urethra has been bruised dur- 
ing labor. Corn-silk is an excellent remedy, in doses of ten to thirty 
drops every four hours. Pariera brava is praised by English writers. 

If there are violent painful spasms of the bladder and urethra, 
gelsemium, in doses of three drops every one or three hours, is a 
potent remedy. (Also phenacetin.) 

Hyoscyamus, belladonna, hydrangea, and viburnum sometimes 
act well in small but not minute doses. In very severe cases when 
immediate relief is demanded, inhalations of chloroform and amyl 
nitrite acts quickly (one drop of amyl to one drachm of chloro- 
form). 

Irritable bladder is a frequent attendant on prostatitis, hemor- 
rhoids, and uterine disorders. In some cases the above medicines 



DISEASES OF THE URINARY ORGANS. 647 

will only act as palliatives. The radical treatment must be directed 
to the origin of the disorders. 



INCONTINENCE OF URINE. 

There are several varieties of this affection : it cannot be called 
a disease, because it is only a symptom of some disease. It may be 
divided into four forms : (1) incontinence in adults ; (2) nocturnal 
incontinence in children ; (3) diurnal incontinence in children ; and 
(4) chorea of the bladder. 

(1) Incontinence in adults may be simply an overflow from reten- 
tion, or " it may be caused by an unsymmetrical development of the 
prostate, when, after the collection of a little urine, the rest trickles 
away, there being no distension of the bladder. It may be caused 
by concentric hypertrophy of the bladder where the viscus cannot 
distend, and all urine above a few drachms must flow at once away. 
Paralysis of the cut-off and sphincter muscles of the bladder, with or 
without paralysis of the detrusor urinae." (Keyes.) 

Nocturnal incontinence of children is one of the most disagree- 
able and obstinate affections that physicians have to contend with. 
It often originates in mismanagement. Mothers allow children to 
drink largely of fluids before going to bed, which should never be 
permitted. Children should be taught to urinate before going to 
bed, else they will fall asleep with a full bladder. Children who 
nrinate at night are generally very sound sleepers, and this deep 
sleep may be caused by the toxicity of the urine. The fact that 
children are sometimes the subjects of diabetes and Bright's disease 
should not be forgotten ; also that the first symptom of these dis- 
eases in children is nocturnal enuresis. Gravel, particularly lithic 
acid, and an acid state of the urine, may be a cause of this symptom. 
It may be a symptom of epilepsy ; the child may have a nocturnal 
epilepsy (petit mal), and the wet bed be the only symptom observa- 
ble. It may be caused by phymosis and the irritating smegma con- 
sequent upon it. The external urethral orifice may be narrowed. 
The prepuce may be adherent to the glands. Thread-worms in the 
rectum or vagina may cause it. It is one of the symptoms of hip- 
joint disease. " In the common form of incontinence occurring at 
night only, the irritability of the muscular coat of the bladder is 



648 THE PRACTICE OF MEDICINE. 

exaggerated, and the resistance of the sphincter is relatively defi- 
cient. There is no atony of the sphincter, but on account of the 
increased pressure against which it has to contend, it requires to be 
strengthened by voluntary agency. During sleep the agency of the 
will is removed and the sphincter can no longer effectually resist the 
action of the irritable muscular fibres, so that the contents of the 
bladder are discharged. In cases when, in addition to the abnormal 
excitability of the muscular coat, there is a certain degree of atony 
of the sphincter, the patient has little control over his bladder even 
in the daytime. The desire to urinate is frequent, and when it 
appears it cannot be retained even for a few seconds." (Eustace 
Smith, " Diseases of Children.") 

This symptom is often intermittent or recurrent. For a week or 
more the bed is wet every night ; then it will remain dry for an 
equal time or longer. When the child is feeling well it disappears, 
to return when the child feels ill or nervous. 

Frightful dreams, or a loud noise at night, cause incontinence in 
nervous children. Spontaneous cures are common ; the child sud- 
denly ceases to wet the bed when no medicine is taken. The child 
u outgrows " it ; some change in the system at seven or fourteen 
years seems to end the trouble. This explains why so many drugs 
get a reputation for its cure. They happen to be given about the 
time of the curative change in the growth of the body. 

Treatment. — The first indication is to remove all apparent exter- 
nal sources of irritation. The elongated and adherent prepuce should 
be removed or dilated, and all its adherent surface separated. The 
external meatus should be cut or dilated. Many cases have been 
cured by the passage of the sound into the bladder. Thread-worms 
should be expelled from the rectum by an enema of naphthaline two 
per cent. The urine, if acid, should be rendered alkaline by the 
bicarbonate of potassium. If ammoniacal, by the benzoate of lith- 
ium or potassium, or benzoic acid. If the frsenum is too short it 
should be clipped. If the rectum should be full of faecal matter, a 
small enema of glycerine and water should be given before the child 
is put to bed. When enuresis, day and night, is caused by irrita- 
bility of the bladder with atony of the sphincter, the remedies are 
belladonna, hyoscyamus, gelsemium, stramonium, corn-silk, triticum 
repens, or equisetum, in the lower potencies. It is a fact that can- 



DISEASES OF THE URINARY SYSTEM. 649 

not be denied by our school, that belladonna and hyoscyamus can be 
given to children in larger doses than to adults. 

The fear of the low dilutions in case of infants is baseless. What 
has been considered aggravations from the use of belladonna in chil- 
dren has been the appearance of symptoms belonging to the disease, 
not the drug. No true pathogenetic symptom has yet been recorded 
from the use of any of the dilutions when given to children. Accord- 
ing to Eustace Smith and many others, cures of nocturnal and diur- 
nal enuresis have been made by the use of doses as large as twenty 
to thirty drops of the tincture three times a day, without any other 
observable symptom than dilatation of the pupils. Sulphate of atropine 
has cured nocturnal enuresis in children in doses of l-500th down to 
1-1 00th of a grain three times a day without causing any disagree- 
able symptoms except dryness of the throat. The indications for 
belladonna, hyoscyamus, and stramonium given in our text-books 
are untrustworthy because they confound primary and secondary 
symptoms and several diverse conditions. For these remedies the 
indications which accord with their primary action are atony or par- 
alysis of the sphincter and cut-off muscles that cannot retain the 
urine when the bladder is partly filled. Here minute doses may 
cure (from the 2x to 6x), but they will have no influence in that sec- 
ondary state of irritable bladder and its sphincter described above, 
where physiological doses are necessary. 

Several cases of nocturnal incontinence in young girls who, not- 
withstanding the fact that they emptied the bladder, wet the bed 
towards morning, 1 have cured with hyoscyamus (mother tincture), 
five drops every evening. Several similar cases were promptly 
cured with hyoscine 3x (1-1 000th grain) three times a day. 

Rhus aromatica has been found very successful in atony of the 
sphincter causing nocturnal urination. The doses have ranged from 
ten drops of the tincture to a drop of the lx. Rhus tox and rhus radi- 
cans are suitable for the worst cases when the urine runs away all 
the time during sleep, day or night, as during or after typhoid fever. 
Nux vomica and strychnine are invaluable in children whose spinal 
energy is so deficient as partly to paralyze the nerves that preside 
over the neck of the bladder. Such children urinate if startled or 
frightened, or while engaged in games during the day ; then the 2x 
of nux and the 3x of strychnine are appropriate. When children 



650 THE PRACTICE OF MEDICINE. 

wake from sleep with fright and great agitation and unconsciously 
urinate, the specific remedies are aurum bromide 2x, or hyoscine 3x. 
Ergot is suitable in enuresis from paresis of the sphincter. In 
large toxic doses it causes tetanic spasm of the sphincter and cut- 
off muscles of the neck of the bladder. This primary effect is fol- 
lowed by the opposite condition, paralysis. The curative doses for 
this paralytic enuresis is five to ten drops of the normal tincture or 
fluid extract, or the lx trituration of good ergotine. Ustilago has 
a similar action. Turpentine has an action almost opposite to ergot. 
Primarily it causes an irritable bladder which overcomes a weak and 
irritable sphincter. The desire to urinate is frequent when awake, 
with inability to hold the urine. When asleep the urine passes fre- 
quently and involuntarily. Turpentine 3x will cure all such cases. 
Erigeron, copaiva, cubebs, and especially cantharides cause similar 
conditions. Some of the most notable cures of obstinate cases ever 
reported have been made with cantharides, in doses ranging from one 
drop of the tincture to the 3x dilutions. 

Ferrum seems to be especially suitable in diurnal incontinence. 
Santonin e is a favorite remedy with many, not because it destroys 
intestinal parasites, but because of its action on the cerebro-spinal 
centres, first as a depressant, second as an excitant. The dose is 
from the lx to 3x trituration. 

Piper methisticum cured six obstinate cases reported by Dr. Pal- 
mer, of Lockport, N. Y. Gandez, of Paris, praises very highly anti- 
pyrin ; several others confirm his recommendation. The usual dose 
is five grains given two or three times in the evening at intervals of 
two hours. 

Dr. Sanger has found good effects from the mechanical method 
of introducing a metallic catheter into the bladder of female chil- 
dren, making firm pressure backward and to the sides several times, 
while the thumb covers the aperture of the instrument. Ten or twelve 
sittings are said to be usually efficient. 

A writer in the London " Lancet " recommends the birch rod 
applied before the child is put to bed, " not as a punishment but in 
a true scientific spirit." Six is the regulation number of strokes. 
After the third seance the cure is complete. The rationale of the 
method is that it awakes in the boy a desire to avoid wetting the 
bed ; it draws the blood to the surface for a few hours, and thus 



DISEASES OF THE URINARY SYSTEM. 651 

relieves the pelvic organs ; it stimulates the lumbar centre control- 
ing micturation through the nerves distributed to the upper gluteal 
region, and prevents the patient lying on the back. Dry-cupping 
would probably be just as efficient. Dr. Kupke thinks it possible 
that incontinence is often the result of a weakness on the part of the 
spinal cord, which loses its power to transmit to the brain the impres- 
sion of distension of the bladder. On the other hand, we must also 
admit that an anaesthetic condition of the sensitive nerves of the 
bladder can occur, by reason of which the micturition centre of the 
spinal cord is only feebly made aware of the need to urinate. He 
recommends Gunyon's method of electrization as most rational. This 
consists in introducing into the urethra as far as the membraneous 
portion a metallic sound, to which an electrode is attached, the other 
electrode being placed over the pubes or on the perineum. The 
current should be quite weak at first. Others apply one of the poles 
over the vertebral column and the other on the symphisis pubis. 
Phosphate of strychnine 3x should cure the majority of such cases. 
All rational physicians denounce corporal punishment. It is cruel 
and demoralizes the child, and never has been productive of any 
benefit. 

Cold sponging in the morning is very serviceable in cases of an 
enuresis that appears to have its origin in general debility. It braces 
up the nervous system and is a powerful tonic. The slight sensa- 
tion of chilliness soon passes away without leaving any depression 
if vigorous friction with a towel be employed for a few minutes. 
The vital functions are brought into a healthier state, the skin acts 
better, and the appetite and digestion improve. However delicate 
the child may be, free sponging in tepid water, followed by a good 
rubbing, is of great value. The water may be used at a tempera- 
ture of 90° at first, and as the child becomes stronger may be low- 
ered to 70°. The reason of most of the failures to cure enuresis is 
that the medicine is not continued long enough. Atropine was used 
in fifty cases in doses of l-500th to l-100th of a grain every evening 
for five months. Nearly two-thirds of the patients were cured in 
periods varying from one to five months. Equisetum may have 
almost immediate good effect, but in some cases it requires to be used 
a month or two. The same can be said of nux vomica, strychnine, 
xhus .aromatica, ferrum, and many if not all the indicated medicines. 



652 THE PRACTICE OF MEDICINE. 

Schuessler recommends for nocturnal involuntary urination phos- 
phate of magnesium for diurnal ; phosphate of iron when from weak- 
ness of the sphincter ; phosphate of potassium when from paralysis 
of the sphincter and nervous debility ; phosphate of sodium when 
from acidity ; and phosphate of lime in general. Now, involuntary 
micturition is not found as a symptom in the provings of these drugs. 
They are recommended theoretically on the bio-chemical theory — a 
theory which Hahnemann denounced with all the vigor of his tren- 
chant pen. There have not yet appeared any clinical reports sub- 
stantiating the recommendations of these medicines in this disease. 

In my " Therapeutics of New Remedies " I collected evidence 
apparently proving the value of bromide of potassium, cedron, chlo- 
ral, eupatorium purp., gelsemium, plantago, rhus aromatica, santo- 
nine, strychnine, and dimiana in the treatment of enuresis. The 
reader is referred to that volume. 

In a recent clinical lecture, Dr. T. F. Allen prescribed success- 
fully for diurnal and nocturnal incontinence, causticum 3x ; together 
with the incontinence this drug has " excessive quantity of urine." 
Its symptoms all point to atony of the sphincter and incompetence 
of the cut-off muscles : for the urine is voided on coughing and any 
sudden exertion. 

Dr. J. P. Tessier, of France, reports that " Eupatorium purp. 
has been a curative remedy in the diurnal and nocturnal enuresis of 
a boy fifteen years old, suffering from this condition since his child- 
hood. It also cured the nocturnal enuresis of two old men, and 
diminished the frequency of the emissions. Same success for one 
tabetic of forty-eight years old ; the locomotor ataxia did not improve, 
but the symptoms of paralysis of the bladder were suppressed." 

Chorea of the bladder, according to Keyes, is a rare affection, 
and only occurs in children. It usually coincides with other choreic 
symptoms. He gives three interesting cases. They were character- 
ized by paroxysms of incontinence ; they sometimes wet the bed, but 
not invariably ; it occurs when at play ; they run to their mother 
when they wet their clothes, declaring they cannot help it. One 
had no other choreic symptom except in one eye; another had 
twitching of the head and shoulders ; a third had general choreic 
twitchings. All had involuntary spasmodic emission of urine, which 
they could not control. I believe I have seen several similar cases, 



DISEASES OF THE URINARY SYSTEM. 653 

but failed to recognize the choreic element. This element we should 
be on the watch for, as the treatment should be quite different from 
that adopted in ordinary cases. Keyes cured his cases with iron and 
arsenic. I would recommend in addition agaricus, arsenite of cop- 
per, cimicifuga, and myalgse. In some cases stramonium and hyos- 
cyamus will be indicated. 

The diagnosis between this affection and irritable bladder will 
be found perplexing, as they have many symptoms in common. 

Lately, phenacetin has been recommended for urinary troubles 
in advanced life. Dr. Traill Green (" Univ. Med. Magazine," June, 
1892) says, " The majority of such troubles present symptoms of 
excess of uric acid or urates in the urine, and the subjects probably 
suffer from rheumatism or gout, and acquire the habit of too frequent 
urination. In many cases there may be an irritability of the blad- 
der. During the past year the writer attended a patient for whom 
he had prescribed for a year or two for frequency of passing urine. 
While under treatment for another affection, he had occasion to 
prescribe a dose of phenacetin, and was glad to learn the following 
morning that the patient had passed the night without a call to pass 
water. The medicine was continued in doses of ten grains for sev- 
eral nights, and rest for eight hours, from 10 p. M. till 6 A. M., was 
produced. The patient did well until the summer vegetables and 
fruit, like tomatoes, were eaten, when night troubles from frequent 
urination returned. Phenacetin was again prescribed, with imme- 
diate relief. The particulars of another similar case are also given. 
The writer has not used this medicine in any case of enlarged pros- 
tate, as that disease requires other treatment. He is satisfied that 
the effect of phenacetin does not depend upon any property which 
it may possess of producing sleep, since the patient may awake 
during the night without being called upon to urinate ; and sulfonal 
and other remedies of the same class, as he has found on trial, do 
not act in giving rest like phenacetin. Phenacetin may be recom- 
mended, if for no other reason than that it allows the bladder to be 
distended for eight hours, and so prevents the reduction of the capac- 
ity of the bladder, as is known to occur when the urine is discharged 
as soon as two or three ounces collect in it ; so that the organ must 
be distended by injections of water to restore it to its usual capacity, 
in order to relieve the sufferings of such as have a bladder con- 



654 THE PRACTICE OF MEDICINE. 

tracted by frequent urination. As to the action of phenacetin, it 
is possible that the bladder is irritated by the urates, and this is 
allayed by this medicine, similarly as it acts in rheumatism and 
neuralgias. The quantity of urine is not diminished, as far as has 
been observed. The writer recommends this treatment, and hopes 
that readers will report such results as they may observe." 

For several years I have used phenacetin and salol for all pain- 
ful bladder diseases, especially chronic cystitis and irritable bladder. 
Both act as sedatives to the nerves of sensation, and the mucous sur- 
faces of the urinary tract. 

In children and sensitive women, the lx trituration in two-grain 
doses every hour or two acts admirably. I do not hesitate to give 
five or ten grains of phenacetin at night if hyoscyamus or conium 
fails to quiet the bladder and allow sleep. 



RETENTION OF URINE. 

Definition. — A condition of the bladder and its neck in which 
the bladder fills up, and the urine is not or cannot be passed. This 
condition must be clearly differentiated from suppression, where no 
urine comes down from the kidneys. The condition can always be 
quickly recognized by percussing the hypogastrium, or by palpation. 
In retention the hypogastrium will be found swollen, and the out- 
lines of the bladder can be felt if the patient has not a great deposit 
of fat in the abdominal parietes. There is dulness on percussion, 
while in suppression, the abdomen is flat, the bladder cannot be felt, 
and there is resonance or tympanitic sound on percussion. 

Causes. — The causes of retention are : (1) Voluntary retention, 
often repeated and long continued. This often occurs in boys and 
girls confined in school, and in women who, from false delicacy, will 
not empty the bladder when it is full. If this practice is kept up, 
it may result in positive inability to void urine owing to paralysis of 
the bladder from over-distension. (2) Spasm of the cut-off and 
sphincter muscles, which may occur from irritability, or reflex causes 
in the rectum, or from mental shock. (3) A blunted sensibility of 
the bladder, such as occurs in fevers, coma, and some brain diseases. 
(4) Urethral obstruction from stricture, calculi, enlarged prostate, 
and urethritis. 






DISEASES OF THE URINARY SYSTEM. 655 

In some cases the retention is not complete, a little urine passing 
away occasionally, or flowing drop by drop during great straining 
efforts. 

Diagnosis. — Pressure on the bladder usually causes a desire to 
urinate. One of the means of diagnosis is to place the hand on the 
region of the bladder, and a finger in the rectum. Fluctuation can 
then be made out. In cases of long retention there is some danger 
of rupture of the bladder, but Keyes says the bladder will not burst 
unless it be previously ulcerated or subjected to mechanical violence 
when full. After it has been over-distended for a time a certain 
amount of dribbling will take place through almost any obstruction. 

Gant (" Diseases of the Bladder ") says : " Unrelieved retention 
of urine leads generally to rupture of the urethra, and especially 
when the source of obstruction is in the urethra, the canal yielding 
behind that point, and this event being followed by extravasation of 
urine." 

Treatment. — No physician will allow a retention of urine to reach 
serious proportions before using the catheter. The safest and best 
to begin with is the soft, velvet-rubber catheter. If this fails, more 
unyielding ones will have to be used. Spasmodic retention of urine 
can usually be relieved by the sitz-bath, warm water applied to the 
genitals, or hypogastrium, or a warm-water enema. There is a curious 
sympathy between the sphincter of the bladder and the sound of run- 
ning water. I have known a great many instances when the open- 
ing of a faucet, or pouring of water from a pitcher or kettle, has 
caused the relaxation of a spasmodically closed sphincter. Chloro- 
form has been useful. In several cases occurring in women and 
girls, a few whiffs of chloroform caused complete emptying of the 
bladder. There are many neurotic men and women who cannot urin- 
ate when another person is in the room, or on railroad cars when they 
are in motion. They must have silence and isolation. 

There are several drugs which cause spasmodic stricture of the 
sphincter of the bladder, and cut-off muscles by an action through the 
nerve centres. Nux vomica, ergot, belladonna, hyoscyamus, have this 
effect primarily, and can be used effectively in spasmodic retention 
when given in very small doses (lx to 3x). Secondarily they cause 
paralysis of the bladder with relaxation of the sphincter, and in such 
cases are very effective in large doses. Other drugs cause spasm and 



656 THE PRACTICE OF MEDICINE. 

contraction of the sphincter vesicae, by their local irritant action. 
Among these are cantharis, turpentine, copaiva, cubebs, pichi, oil 
of sandal-wood, equisetum, cannabis, apis, and many others. When 
these are indicated by their primary symptoms the smallest dose suf- 
fices to remove the local irritation of the neck of the bladder. I have 
known the 6th of cantharis and turpentine to give quick relief. All 
these drugs also cause, secondarily, a paresis of the bladder, a blunted 
sensibility, and even complete paralysis, which at times leads to reten- 
tion, at other times to incontinence of urine. When secondarily 
indicated the dose must be stronger — the lx, or even five or ten 
drops of the tincture. This is not theoretical, but is substantiated 
by my own experience and the clinical records found in old-school 
practice. The law of similia is potent in and applies to both con- 
ditions. 



ACUTE INFLAMMATION OF THE PROSTATE. 

Diseases of the prostate gland afford a most interesting study. 
They cause as much pain and suffering in men, as do diseases of the 
uterus in women — with which organ it is homologous. 

I shall quote largely from Sir Henry Thompson's great prize 
essay on " Diseases of the Prostate," the most complete monograph 
yet written. 

" Acute inflammation of the prostate," he writes, " is by no 
means a common affection, if regarded as distinct and unassociated 
with inflammation of the urethra or bladder. When the latter organ 
is inflamed, the prostate appears sometimes to suffer, although in a 
secondary manner and degree. But in obedience to the common 
law which seems to apply to tracts of mucous membrane generally, 
inflammation appears commonly to travel from the external to the 
deeper parts. Accordingly, an attack of urethritis, involving the 
external inch or two of the urethra may spread inwards and fix itself, 
as I believe is not infrequently the case, upon that portion of the 
canal which is most largely surrounded by vascular tissue, viz., the 
bulbous portion. Hence, probably, the origin of stricture-formation 
affecting that locality especially. But it may proceed, as an excep- 
tional occurrence, more deeply still, and the prostate becomes the 
subject of inflammatory action. Such is the most common mode by 



DISEASES OF THE URINARY SYSTEM. 657 

which this organ is involved. It may not be out of place to observe 
that in the respiratory tract the same line of march from the exter- 
nal to the internal parts is observed. A catarrh, for example, is the 
first sign of inflammation in the mucous membrane of this region ; 
the action may gradually spread to the throat, larynx, bronchi, and 
so on to the lung-substance itself. The converse order of things we 
do not observe ; and after the same manner also in the genito-urinary 
tract we find that inflammation is to be traced, as a rule, from the 
urethra to the prostate, bladder, ureters, and, last of all, it may be, 
to the kidneys. Sometimes, however, the prostate is inflamed appa- 
rently as a purely idiopathic occurrence, and from continuity of 
tissue with adjacent parts. This, excepting the cases produced by 
violence, as by instruments, etc., is probably extremely rare. 

"Causes. — Systematic writers on this subject enumerate many 
circumstances as giving rise to acute inflammation of the prostate. 
The relation between some of these and the supposed effect appears, 
however, to be less clear than the precise statements generally made 
might lead the inquirer to imagine. The alleged causes may be 
arranged for consideration in three classes, as follows : 

" (a.) Undoubted causes of acute prostatitis. 

The pre-existence of acute inflammation of the urethra of any 
kind, but especially the gonorrhoea^ by continuity, as already 
alluded to. 

Urethral stricture in an aggravated form, tending as it does to 
the production of inflammation and disorganization of all the parts 
posterior to it, especially those more immediately adjacent, as the 
prostate and bladder. The direct application of irritating agents in 
the shape of strong injections, cauterization, and mechanical violence 
of various kinds. Inflammation of the bladder sometimes. Cal- 
culi of the bladder and of the prostate itself. The application of 
cold and damp to the perineum, as by sitting for a long period on 
moist ground. Urethritis has been referred to as a proximate cause, 
but it may also be the remote cause in the circumstances last enumer- 
ated, as well as in some of those which come under the next head. 

" (b) Circumstances which cannot be stated with absolute cer- 
tainty to be causes, but which may, with some amount of probability, 
be so regarded. Horse-exercise is constantly said to be a cause of 
acute inflammation in the organ, by means of the concussion occa- 



658 THE PRACTICE OF MEDICINE. 

sioned. Evidence is wanting, I think, to establish this. That it 
may aid in producing it when some inflammation of the urethra 
already exists is quite possible. Certainly it cannot be said that 
hard riders, such as huntsmen, jockeys, but above all the cavalry 
soldier, from the nature of his seat, are in any notable degree more 
subject to it than other men equally exposed to other and better rec- 
ognized sources. Cantharides may, perhaps, occasionally act as a 
cause when taken internally, but probably never without primarily 
affecting the kidneys and also the bladder." 

It has never been proven that bicycle riding has caused injury 
to the healthy prostate. 

" Alcoholic drinks, especially when mixed with acids, as punch, 
may induce prostatic inflammation, gonorrhoea already existing, but 
only on this condition. Inordinate sexual intercourse, under the last 
named circumstances, may probably be assigned also to the present 
category. 

" (c) Circumstances stated to be causes by numerous authors, 
but respecting which there is either little or no evidence to render it 
probable that they are so. 

" Diuretic medicines, copaiva, cubebs, and turpentine, even cof- 
fee and highly-seasoned dishes, are said to cause inflammation of 
the prostrate. Drastic purgatives are similarly regarded by some. 
Irritation in the rectum by ascarides, hemorrhoids, etc., are enum- 
erated as causes. All these may, and do undoubtedly, sometimes 
induce an irritable condition of the bladder, and some of them, per- 
haps, even some degree of inflammation of the viscus ; but I am not 
aware of any authenticated case of acute prostatitis directly or indi- 
rectly occasioned by any of these agents. 

" The morbid condition of any of the organs which exist in the 
presence of carcinomatous infiltration, or of tuberculous deposit, can- 
not be regarded as by any means identical with the affection now 
under consideration. Nevertheless, the diseases referred to are com- 
monly enumerated as causes. Such a course appears to involve con- 
fusion, and to destroy the definite meaning of terms, which it is 
extremely desirable in all pathological studies to maintain distinct 
as far as possible. Sedentary habits are spoken of as a cause of the 
affection, but without the slightest shadow of evidence to support 
the assertion, as far as I have been able to discover. The same also 



DISEASES OF THE URINARY SYSTEM. 659 

may be said with regard to a constipated habit of body. It is prob- 
able that want of exercise and a torpid state of the bowels both 
tend to induce a loaded condition of the veins of the abdomen, and 
among them those of the prostate ; and in this manner a mechanical 
congestion of these vessels, which are prone to be large and dilated, 
as well as of the proper capillaries of the organ, is doubtless fav- 
ored ; but that this can be considered causal, even in a secondary or 
predisposing relation, of acute inflammation it is not very easy to 
believe." 

Horseback and bicycle riding have been assumed to be a cause of 
prostatitis, but without sufficient proof. Thompson says the English 
cavalry suffer no more than others, and Dr. W. S. White, of Chi- 
cago, in the " Clinical Reporter," writes, " If the saddle is properly 
adjusted the rider can sit on the tuber ischii, and have very little 
pressure on the perineum." 

" Symptoms. — At the outset, a sensation of weight and fulness 
about the rectum and perineum is experienced, with some pain and 
uneasiness referred to the neck of the bladder. The patient required 
to pass water more frequently than natural, and does so with an 
increase of the existing pain, especially at the close of the act. 
These symptoms increase ; the pain becomes severe, then lancinating 
and pulsatile, and almost continuous ; a sense of tension and swell- 
ing is experienced, and the anus and perineum are tender when 
pressed upon. Movements of the body become difficult on this 
account, as does also the sitting position. The act of relieving the 
bowels at stool produces considerable distress ; still more so does 
the act of micturition ; the stream of urine being generally small, 
and its passage necessarily prolonged, much straining accompanies 
it, and the pain is exquisitely acute. As the organ increases in size 
and tension, complete retention of urine may occur and continue for 
some days. In these circumstances a finger introduced into the rec- 
tum encounters much opposition, however quietly it is carried through 
the sphincter ; the anterior wall of the bowel is prominent, hard, 
and hot, and the outline of the prostate may be traced, not, how- 
ever, without causing great suffering to the patient. An attack or 
piles may be induced, the close contiguity of the hemorrhoidal and 
prostatic veins appearing to favor this result. At a later stage, if 
suppuration has taken place, the rectal swelling is softer, local throb- 



660 THE PRACTICE OF MEDICINE. 

bing is experienced, and should a catheter be passed, the patient will 
complain of excessive pain when the instrument reaches the pros- 
tatic part of the urethra. General fever, in a greater or less degree, 
manifests itself after the accession of the earlier local symptoms, 
rigors and exacerbation accompanying the onset of suppuration. 
Pains in the back and loins, as well as in the glans penis, and run- 
ning down the thighs, are experienced, and not infrequently a sen- 
sation of constant desire to go to stool. The mucous membrane of 
the bladder participatess sometimes, not always, in the inflammation ; 
the urine is febrile in character, and contains mucus to some amount, 
occasionally in considerable quantity, the latter condition if the last 
named structure is implicated. Besides this, there may be pus in 
the urine to a greater or less extent, from which it is deposited as a 
sediment on standing." 

" The chief signs upon which a diagnosis depends may be noted 
as follows: Enlargement of the prostate, ascertained by rectal exam- 
ination, the prosecution of which is extremely painful to the patient, 
with acute pain complained of when pressure of the finger is made 
upon any part of the swelling there. The act of defecation is often 
productive of much distress ; that of micturition still more so, com- 
plete retention often supervening. If the catheter is introduced, 
exquisite suffering is caused when it arrives at the prostatic part of 
the urethra. Added to these, there is a constant and deep-seated, 
often throbbing, pain felt about the fundament. These symptoms 
alone, but especially when associated with a history of recent ure- 
thral discharge, which may have previously ceased or not, will suffice 
to determine the nature of the case." (Keyes.) 

Treatment. — Sir Henry Thompson considers it very important 
that the rectum should be kept free from fsecal matter. Nor should 
fsecal matter be allowed to remain in the colon. I have often given 
quick relief from the pain, throbbing, and constant desire to urinate 
by a hot rectal douche when anodyne suppositories failed. The small- 
est piece of hard fseces in the rectum will cause great pain in an 
inflamed prostate. The local abstraction of blood by means of 
leeches was once considered important. No doubt the abstraction 
of a few ounces of blood from the anus and perineum will lessen the 
pain and engorgement temporarily. I do not think the relief is per- 
manent. The hip-bath and a poultice to the perineum are both useful 



DISEASES OF THE URINARY SYSTEM. 661 

The sitz-bath should be continued eight to ten minutes, the water at 
first at 80°, raised gradually to 105°. 

" One of the most troublesome conditions met with is retention 
of urine caused by the barrier which the swollen prostate offers to 
micturition. The stream diminishes, at last ceases, and it is then 
absolutely necessary to pass a catheter as many times in the day as 
the comfort of the patient requires ; four times in twenty-four hours. 
The best instrument as a rule is a flexible catheter, well curved, and 
of rather small size, say No. 5, 6, or at the most 7. It is to be 
removed as soon as the bladder is emptied, and employed so long as 
the bladder is not emptied by the natural efforts." (Thompson.) 

We should watch for fluctuation. If it is deep, the pus may be dis- 
charged when using the catheter. If it can be readily felt through 
the rectum, an incision should be made. 

The diet should be cooling, bland, and containing no seeds or 
hulls which might lodge in the rectum. Coffee and all alcoholic 
beverages should be strictly prohibited. Rice, wheatena, granulated 
barley, milk-toast, milk, Vichy water, spinach, and apple-sauce are 
all that is necessary until the inflammation and swelling is reduced. 
It is often a month before the size of the prostate and its tenderness 
entirely disappears and much longer if the patient will not keep quiet 
and diet properly. The medicines most appropriate for acute inflam- 
mation are aconite, veratrum viride, gelsemium, and belladonna, pre- 
scribed as the symptoms indicate. 

Aloe is indicated if the inflammation has been caused by purga- 
tives, or is connected with piles ; cantharides when it arises from 
excessive sexual indulgence ; copaiva when it is connected with gon- 
orrhoea (cubebs and sandal- wood when from the same cause); gel- 
semium is almost specific when prostatitis results from suppression 
of a urethral discharge by astringent injection ; the discharge soon 
returns, with relief to the inflammation. Pulsatilla, chimaphila, 
thuja, senecio, apis, are often indicated. Digitalis, recommended by 
Lippe, is useless, as it has no affinity for the prostate. 

CHRONIC PROSTATITIS, 

The most complete and scientific description of this disease is 
found in Sir Henry Thompson's great work on the Prostate. This 
has been admirably utilized by Dr. Keyes in his " Diseases of the 



662 THE PRACTICE OF MEDICINE. 

Grenito-ITrinary Organs," who has added matters of great value from 
his wide experience. 

" Chronic prostatitis," says Keyes, " is met with in three differ- 
ent phases, but the symptoms and pathological characters are much 
the same in each, and differ in degree rather than in kind. It may 
originate solely in an attack of acute prostatitis, and be due to a 
morbid persistence of unhealthy action, which shows no disposition 
after the acute symptoms have subsided ; or secondly, there may be 
a long and tedious resolution, naturally leading, but by slow steps, 
to the reestablishment of healthy action ; and, finally, the condition 
may commence in the chronic form, independently of any acute 
attack, in which case it may be the primary or sole existing com- 
plaint, or it may be dependent on disease of adjacent organs. 

" It is common to meet with instances in which simple chronic 
inflammation of the prostate, producing enlargement, is regarded as 
an example of hypertrophy. Yet nothing can be more distinct than 
the two affections, if we compare their pathological history and 
characters. Chronic inflammation, however, by no means neces- 
sarily causes enlargement of the organ ; indeed, this is an excep- 
tional condition, all varieties considered. But when inflammatory 
enlargement does exist, it is almost invariably in the early or mid- 
dle periods of life ; while hypertrophy never occurs before the fif- 
tieth, very rarely before the fifty-fifth year, and it is not commonly 
manifested by symptoms before the fifty-seventh or eighth year. 
Inflammatory enlargement is almost invariably preceded by some 
urethral inflammation. Urethral discharge of a purulent nature, 
urine containing small flocculi, and pain during and after micturi- 
tion, have been or still continue present. Associated with these, 
there is often an impaired condition of the general health. All 
these may be, and usually are, absent in hypertrophy during its 
earlier stages. Finally, inflammatory enlargement is due to the 
effusion of morbid products, lymph, pus, etc., into the substance of 
the organ ; while a hypertrophic enlargement is due, as the term 
implies, to simple over-production of the normal elements of the 
prostate gland itself. 

" Causes. — The most fertile cause of chronic prostatitis is gonor- 
rheal inflammation, which has extended backwards and affected, 
more or less acutely, the prostate. Local cold and damp must be 



DISEASES OF THE URINARY SYSTEM. 663 

recognized as occasionally producing it ; more rarely still it is due 
to mechanical injury inflicted on the urethra or in the perineum. 
Long-continued indulgence in venereal excesses of any kind is un- 
doubtedly a cause. That form which results from long-standing and 
severe stricture of the urethra, of chronic cystitis, of calculus, either 
vesical or prostatic, is common enough, and needs no separate con- 
sideration ; it is the mere result of existing adjacent disease, upon 
which it altogether depends." 

"Symptoms. — A patient who suffers from simple, uncomplicated 
chronic inflammation of the prostate complains of a little undue fre- 
quency in making water, sometimes of muco-purulent discharge from 
the urethra, of a sensation of weight and fullness, sometimes of dull 
pains in the perineum and about the anus, which may be occasional 
or persistent, but which are almost always increased by exercise ; 
often of pains in the thighs and legs, or in the sacral region ; some- 
times increased, but not invariably, by sexual intercourse. 

" There is usually no pain in micturition until the end of the act, 
when it is occasionally but by no means always felt, and then it is 
never very acute like that of calculus. There may be tenderness in 
the perineum, sometimes felt in the sitting posture ; tenderness in 
the prostate itself to rectal examination ; an irregularity in form is 
sometimes detected by the finger, but this is exceptional ; and there 
is not necessarily any enlargement. The passing of a catheter gives 
more than usual pain when it traverses the prostatic urethra and neck 
of the bladder. The urine is a little cloudy, but on examination this 
condition is found to be mainly due to shreds of tenacious muco-puru- 
lent matter, and masses of epithelium, which have their origin in the 
prostatic urethra and not in the bladder, as may be ascertained by 
desiring the patient to pass water into two glass vessels, the first 
ounce or so into one, the remainder into the other, when all the pur- 
ulent matter will be found in the former portion, while the latter is 
clear. This mode of examining the urine is one to which I attach 
considerable importance. It separates purely urethral products from 
the deposits which come from the bladder or from the kidneys, and 
which are otherwise likely to be attributed to the latter sources, or 
at all events to be misunderstood. For all purposes of urine exam- 
ination this proceeding ought to be pursued. In well-marked cases, 
there appears at the end of micturition a drop of blood, sometimes 



664 THE PRACTICE OF MEDICINE. 

more than that, tinging the last portion of the urine passed — an 
occurrence often leading to a suspicion that calculus exists. This 
sign, as well as the simultaneous pain experienced, and the fact that 
the symptoms are increased by much exercise, often gives rise to a 
necessity for sounding in order to determine the question. Indeed 
I know of no other complaint which so strongly resembles by its 
symptoms stone in the bladder in a mild form, as it is occasionally 
observed when the foreign body is small and produces little irrita- 
tion." 

" Further inquiry will frequently discover that the patient has 
little or no sexual desire, and he may or may not be the subject of 
frequent involuntary seminal emissions during sleep. The health 
is mostly somewhat impaired, and general debility complained of." 

Keyes (" Diseases of the Genito-Urinary Organs ") makes three 
kinds of prostatitis : (1) parenchymous, (2) follicular, (3) gonor- 
rhoeal. His follicular variety corresponds to Thompson's chronic 
prostatitis. This disease has also been called prostatorrhoea. 

I doubt if either variety exists alone, except in rare instances. 

Treatment. — The first requisite in acute or chronic cases is abso- 
lute rest. The bladder, rectum, and sexual organs must be kept in 
a quiescent condition. The rectum should be kept empty by ene- 
mata of hot water given several times a day. If a small faecal mass 
— a scybalum — is left in the rectum it will irritate the prostate and 
neck of the bladder. If the injections do not wash it out, remove it 
with the finger. The position should be recumbent, with hips ele- 
vated as much as consistent with comfort. This will lessen the desire 
to urinate and prevent congestion. 

To lessen the pain and constant desire to urinate, in addition to 
our specific medicines we are often obliged to resort to special ano- 
dynes, like morphine, opium, belladonna, hyoscyamus, corn-silk, trit- 
icum repens, etc. The fluid drank should be alkaline like Yichy or 
seltzer. A little lithiated potash is excellent in some cases. Infu- 
sions of marshmallow, flax-seed, galium, quince seeds, and other 
mucilaginous drinks should be freely taken. Suppositories made of 
codeine, hyoscyamus, iodoform, ichthiol, or opium are sometimes 
required. The medicinal treatment of chronic parenchymous prostati- 
tis should be conducted along the same lines as that of chronic metri- 
tis, for the prostate and the uterus are homologous organs. The object 



DISEASES OF THE URINARY ORGANS. 665 

to be attained is to prevent such proliferation of tissues as will lead 
to hypertrophy, namely, areolar hyperplasia. The most appropriate 
remedies are ergot, ustilago, thuja, cimicifuga, sabal serrulata, con- 
ium, hydrastis, and aurum. Sabal (saw palmetto) is doubtless pri- 
marily homeopathic to this form of prostatitis, and should be given 
in small doses of the lx or less. Primarily it is a powerful stimu- 
lant to all the glands, especially those belonging to the generative 
system — in this respect resembling aurum ; while ergot, hydrastis, 
and the others act physiologically, depressing undue functional and 
proliferative activity. The remedies for follicular and gonorrheal 
prostatitis belong to another class : those capable of causing in large 
doses a similar condition. Chief of these are copaiva, sabal, thuja, 
cubebs, buchu, sandal-wood oil, kava kava, turpentine, mercurius, 
eucalyptus, cannabis, senecio, etc. Iodide of potassium has been 
theoretically advised in chronic follicular prostatitis with enlarge- 
ment, but success has rarely attended its use in large doses. Dr. 
Freer ("N. A. Jour, of Horn.," 1890, p. 647), however, reports a 
case attended by spermatorrhoea, in a man aged twenty-four, which 
he greatly relieved by iodide of potassium, 30th. I may be excused 
from expressing the opinion that no form of iodine is homeopathic 
to enlarged glands. If the 30th did any good in the above case, it 
benefited the follicular inflammation. 

Select the medicines carefully according to the symptoms and 
pathological state ; prescribe it in small doses of the crude drug, or 
lx to 3x, and continue its use persistently until the symptoms 
improve, then lessen the dose but do not suspend it, for I do not 
believe in the rule adopted by some of our school that we should not 
continue a medicine after improvement sets in. It is not a natural 
law. If an aggravation should occur, it will then be proper to les- 
sen the dose or suspend it, but not during an improvement. Dur- 
ing the treatment of chronic prostatitis all stimulating food and 
drinks should be avoided, and only moderate exercise indulged in. 
Horseback or bicycle riding will retard the cure. Equally impor- 
tant is it that the mind should be kept free from sexual thoughts 
and emotions. Indulgence in intercourse should be forbidden. It 
keeps up an abnormal congestion of the prostate and contiguous tis- 
sues which is inimical to the necessary physiological rest. If sex- 
ual excitement is persistent, recourse must be had to appreciable 



666 THE PRACTICE OF MEDICINE. 

doses of conium, salix niger, damiana, or one of the bromides. 
Keyes and Thompson insist on the value of blisters to the perineum, 
and injections of mild solutions of nitrate silver into the prostatic 
urethra (five or ten grains to an ounce of water), but I have never 
had occasion to use such measures, and where I have observed their 
use in the hands of surgeons the results were not as satisfactory as 
could be desired. 

HYPERTROPHY OF THE PROSTATE. 

Under this head I refer to the enlargement which is an accom- 
paniment of age (from fifty to seventy-five years), not the enlarge- 
ment after inflammation, occuring in youth and middle age. Keyes's 
description of this condition is clear and less prolix than Thompson's, 
and is admirably presented. I quote the essential part of his des- 
cription : 

" The morbid condition to which the prostate is most liable is 
hypertrophy, either general, partial, or by the development of cir- 
cumscribed tumors. In general hypertrophy the glandular elements, 
instead of being hypertrophied, often become atrophied by the exces- 
sive growth of fibrous and muscular tissue between them. In marked 
cases they are completely destroyed, and the prostate is converted 
into a homogeneous fibro-muscular tumor. The isolated circum- 
scribed prostatic tumors, however, always show new formation of 
gland tissue. 

"Cause. — The cause of hypertrophy of the prostate is totally 
unknown. The numerous hypotheses which have been advanced by 
authors need not be discussed : they do not cover the ground. No 
known diathesis, or combination of circumstances, can account for 
the affection. It is not venous stasis, or excessive use of the organ, 
or sedentary life. All that can be said is, that the disease does not 
occur before middle age, rarely before fifty — Thompson says fifty- 
five. 

" The prostate is analogous to the uterus in the female in regard 
to the nature of the muscular tissue which composes it, and this 
analogy is further borne out by the tendency of both organs to 
develop fibrous tumors (so-called) after middle life. Velpeau sug- 
gested this analogy, and justly. The portion of prostatic tissue 
which hypertrophies is the muscular, and not the glandular (or only 



DISEASES OF THE URINARY SYSTEM. 667 

to a small extent) ; and although general or partial enlargements of 
the prostate are the rule, yet it is rather rare for any considerable 
hypertrophy of the organ to be found without the coexistence of one 
or more circumscribed tumors, which correspond to the circumscribed 
fibrous tumors of the uterus, also composed mainly of unstriped 
muscles. Bayle says that twenty per cent of women, after thirty- 
five, have fibrous tumors of the uterus, the cause, of course, unknown. 
Thompson says that thirty per cent of males, after fifty, have fibrous 
tumors of the prostate. He states that moderate enlargement of 
the prostate may be expected in one out of three men ; after fifty, 
marked enlargement in one out of every eight, but rarely before 
sixty. Thompson believes that the affection rarely commences after 
seventy. He quoted, from Beith, the case of an old man who died 
at one hundred and three, where the only abnormal conditions found 
were hypertrophy of the prostate and a sacculated bladder." (Keyes.) 
Size and Shape. — No positive limit in size can be named. The 
prostate may be encountered of the size of a man's fist. Thompson 
has seen the transverse diameter exceed four and a half inches. The 
weight of twelve ounces has been reached. This excessive amount 
of enlargement, however, is rare — a prostate as large as a small 
orange being infrequent. 

" The portion most frequently involved, either alone or (usually) 
associated with more or less general hypertrophy, is the posterior 
median part, known since Sir Everard Home as the third lobe. 
This nomenclature, however, is inexact. The prostate has no third 
lobe, and what Home, from his dissection of diseased / prostates, 
named the 'third lobe' is really a pathological formation, and is 
now more correctly styled median centric hypertrophy. It consists 
of that triangular part of the prostate lying between the ejaculary 
ducts, and overgrowth in this situation is believed to be due to the 
absence of capsule here. It may be found with little or no enlarge- 
ment elsewhere. In form it is usually an oval, rounded tumor 
(there may be two or more), which grows up from the floor of the 
l>ack part of the prostatic urethra and juts out posteriorly into the 
cavity of the bladder. It may reach the size of a small pear, and 
indeed resemble a pear in shape, showing a tendency to peduncula- 
tion. 

■*' When hypertrophy invades the lateral lobes, only one may be 



668 THE PRACTICE OF MEDICINE. 

affected, but usually both, more or less general enlargement corres- 
ponding with the local overgrowth. Under these circumstances the 
pyriform central tumor tends to fill up the internal orifice of the 
urethra, leaving a passage on either side along its floor for the urine. 
The mucous membrane on either side of the central mass is often 
drawn up between it and the hypertrophied lateral lobes, forming a 
crescentic bar at the neck of the bladder. 

Imbedded in the hypertrophied mass, it is usual to find several 
small circumscribed tumors, dense, hard, seemingly fibrous in char- 
acter, easily enucleated and elastic, so that, when cut through in a 
clean section of the organ, the cut surface of the tumor overrides 
the general smooth plane of the incision, as if the little mass had 
previously been compressed. They are formed of unstriped muscle 
with some new glanular tissue, and are considered analogous to mam- 
mary glandular tumors, or to glandular bodies which develop (path- 
ologically) in and around the thyroid. These tumors, usually small, 
may become as large as a marble ; many are found of the size of a 
pea." (Keyes.) 

The central median hypertrophy mentioned by Keyes and Thomp- 
son is the cause of nearly all the unpleasant symptoms. There is 
also, in many cases, a hypertrophy of the mucous membrane just 
behind the prostate, which forms a " bar " and interferes with the 
passage of urine from the bladder to the urethra. This obstruc- 
tion does not merely cause difficult and painful urination but inev- 
itably leads to disease of the bladder. The bladder is never com- 
pletely emptied. The muscular fibres of the bladder are not able to 
contract sufficiently to bring the floor of that viscus above the level 
of the dam at its mouth. This residual urine causes no symptoms 
at the time. It becomes mingled with fresh supplies of urine coming 
down from the ureters. After a time, however, mucus from the con- 
gested membrane around the base of the bladder, being partly 
retained in the residuum, acts upon the latter, setting up decomposi- 
tion of urea and liberating carbonate of ammonia, which irritates 
still further the mucosa of the bladder, until there obtains a com- 
plete pathological picture of chronic catarrh of the bladder which has 
been described on previous pages. Not only does it cause catarrh 
of the bladder but the prostatic obstruction causes structural changes 
in the bladder walls. The muscular tissues hypertrophy, the walls 






DISEASES OF THE URINARY SYSTEM. 669 

are thickened, the contractions are powerful, and great irritability is 
present. In other cases the bladder becomes dilated, sacculi form, 
and an atonic state of the viscus obtains in which the power to expel 
the urine is nearly or altogether lost. In many cases there is an 
extension of the mucous inflammation from the base of the bladder 
upward until the ureters and kidneys are seriously affected. 

Dr. Keyes gives such a graphic description of typical cases and 
the course of its symptoms that I quote it entire : 

" Course and Symptoms. — During all the time that these patho- 
logical changes have been going on, a period of many months, perhaps 
years, ever since there began to be a little hyperaemia around its neck, 
the bladder has been getting gradually irritable. The patient does 
not readily notice it, and will never be able to fix a precise date for 
the commencement of his troubles. An old man does not sleep 
soundly or pay the strictest attention to the performance of his habit- 
ual functions, and he so gradually acquires the habit of getting up 
a little earlier than usual in the morning to empty his bladder, that 
he pays no attention to it. Soon he finds that he wakes up once at 
night, perhaps twice, with a feeling of fullness in the bladder. He 
passes water, and goes to sleep again. He is also troubled a little 
more frequently than usual in the daytime, but he looks upon it as 
a condition natural to advancing life. He has learned that the little 
ills of the flesh, if let alone, usually regulate themselves. He has 
passed water without trouble for fifty or sixty years, and he thinks 
that he ought still to be able to manage it without applying to his 
surgeon. He shrinks from acknowledging a weakness, which he 
must admit to be, if nothing more, a symptom of advancing age, and 
so he goes on lulled to security, making water at intervals which 
gradually but steadily become shorter, getting up perhaps every hour 
at night, and constantly annoyed by a faint, obscure sense of weight 
and heaviness about the lower part of his belly, with, perhaps, a 
fullness in the rectum, and a dull pain behind the pubes. The blad- 
der now is never empty ; but the patient does not know it. Only 
an excess above a certain residuum can be passed off. The old man 
notices, also, perhaps, that he has to wait a little while before the 
urine begins to flow, that the stream is small, and is not projected 
away from him with any force, and that perhaps a part of the urine 
dribbles down perpendicularly from the meatus, while the rest flows 



670 THE PRACTICE OF MEDICINE. 

as a continuous stream. Possibly he cannot make the 'coup de 
piston/ the final spasmodic clearing of the urethra, and finds that 
a few drops dribble away upon his clothes after each urinary act. 
He does not experience quite as much ease and relief as usual after 
micturition ; but this has come on so gradually that he disregards 
it. He finds, however, when he has jolted through the streets in a 
carriage or car, that his calls to urinate are even more frequent than 
usual. 

" At this juncture he dines out, and drinks a glass or two of 
wine more than usual, or he neglects a call to urinate, or gets a wet- 
ting, or his feet or legs get chilled (the latter a very common cause 
of trouble), and suddenly he finds that he cannot pass water at all. 
After vainly trying at intervals for a number of hours, if he does 
not seek surgical relief, at last the urine will begin to dribble away 
from him. The bladder has been distended to its utmost, the mouth 
of the urethra has been dragged open slightly, and the excess of 
urine trickles involuntarily away. This is overflow and not incon- 
tinence. Meantime the patient has been suffering the torments 
known only to those who have had retention, and he hails the over- 
flow with delight, believing that his sufferings are about to cease. 
The hope is vain. The congestion of the bladder-neck, brought 
on by the use of liquor, or by the chilling, and which, added to the 
already large prostate, has swollen it sufficiently to shut up the 
urethra entirely, subsides shortly. Gravity, and the contractions of 
the abdominal muscles and of the diaphragm, are together able to 
dispose of a certain excess of urine, which the overstretched bladder, 
now in a condition of atony, is unable to void. The patient, per- 
haps, recovers from his overflow, but his residuum is greatly in 
excess of what it was before his attack of retention, his calls to uri- 
nate are more frequent, he is disturbed more often at night. All 
his former feelings of uneasiness and pain about the hypogastrium 
and perineum are increased ; digestion is impaired ; the appetite 
fails ; and, worn out by loss of sleep, inability to eat, and constant 
uneasiness amounting to actual pain, the sufferer runs down, aging 
rapidly, and becoming fretful and irritable, losing all interest in bus- 
iness, and nearly all pleasure in life." 

Treatment. — The management of enlarged prostate may be divided 
into three methods : (1) surgical, (2) mechanical, (3) medicinal. 



DISEASES OF THE URINARY SYSTEM. 671 

Of the first I shall not write, but refer the reader to standard 
works on surgery and especially the writings of Drs. Keyes and 
Helmuth. 

The mechanical treatment refers to the use of the catheter, which, 
after the enlargement has reached a certain degree, is essential and 
most important. Sir Henry Thompson and Keyes give the most 
explicit and practical directions for the use of the various forms of 
catheters. I will only add that I advise those who have not had a 
large experience with the catheter to begin with the soft rubber or 
velvet catheter. It will answer the purpose in all cases except when 
there exists a " bar " or " dam " at the neck of the bladder, in which 
case Mercier's and similar catheters are the best instruments. While 
1 advise that the catheter should be used as soon as it becomes actu- 
ally necessary, I believe it is often resorted to before a real necessity 
for it exists. For instance, a man with enlarged prostate catches cold* 
or drinks too much wine or whisky. He finds that, owing to a con- 
gestion of the prostate and an irritability of the neck of the blad- 
der, he cannot micturate. He applies to a physician, who introduces 
a catheter. It is the first time it has been introduced perhaps. 
The bladder is emptied, but the catheter has caused some irritation 
and has to be used again, and such is the tendency of the bladder to 
take upon itself a habit that it becomes necessary to use it regu- 
larly. Now if the man had taken a hot hip-bath or a hot enema, 
drank some alkaline water and been given nux vomica, cantharides, 
cannabis, or hyoscyamus, the power of micturition would have been 
restored in a few hours without the use of the catheter. 

When a man with an enlarging prostate first finds a difficulty in 
starting the flow of urine his first impulse is to strain. If there is 
no bar or dam, nor any spasm of the cut-off muscles, he is able by 
the straining effort to force the urine out of the bladder. But if 
either of the above obstructions exist, his straining will only increase 
the difficulty. The bladder will force the bar or dam against the 
vesical outlet and the urine cannot pass it. Patients should be 
instructed never to strain when urinating. Instruct him to grasp 
the penis, just behind the glans, with the thumb and forefinger, or 
with the whole hand, to compress the urethra and wait until he feels 
the urine filling the urethra to the point of painfulness ; then to let 
go. He will find the stream of urine will be large, and will be pro- 



672 THE PRACTICE OF MEDICINE. 

jected a considerable distance. This may have to be repeated until 
the bladder is emptied, but sometimes one compression will so open 
the vesical orifice that micturition will go on easily to the end. 
The explanation of this is, that by compressing the urethra, the 
urine after filling it, backs up against the valve-like dam or bar and 
pushes it open, allowing the urine to pass over it and out of the 
bladder. By following this plan intelligently a man may be saved 
from using the catheter for many years. If the obstruction be a 
spasm of the cut-off muscles, this method is not so certain. In such 
case advantage should be taken of the relaxing effect of warm ene- 
mata or the sound of running water from a faucet or a pitcher. The 
introduction of the faucet in public urinals has been a great boon 
to patients of both sexes who have irritable cut-off muscles. I have 
observed, also, that many persons find it difficult to micturate until 
they have drank a little water. Sometimes merely rinsing the mouth 
with any fluid will relax the cut-off muscles. In some severe cases, 
especially in women, a few whiffs of chloroform or amyl nitrite will 
have a very happy effect. 

The state of the rectum has much to do with the ability to mic- 
turate. Many cannot urinate until they have a movement of the 
bowels in the morning or empty the rectum with enemas or with the 
finger. The fsecal mass presses on the prostate or forces the dam 
against the vesical opening ; or the pressure may irritate the neck, 
causing spasm. 

I have known large and small hardened masses to cause frequent 
and scanty micturition without relief. Remove the scybala and the 
bladder will empty itself. 

Hemorrhoidal tumors, internal or external, greatly aggravate the 
dysuria in prostatic enlargement. They should be removed or reduced 
in size by some means. The influence of the knee-elbow position for 
five to ten minutes when the rectum is empty will drain the turgid 
veins and allow protruded piles to go back. Then it will be found 
that micturition will be easier. 

Medicinal Treatment. — The dominant school have but little con- 
fidence in the powers of drugs to reduce the size of true hypertrophy 
of the prostate. The late Dr. Atler, of Philadelphia, believed that 
ergot has some specific influence because it caused unstriped muscles 
to contract. He argued from this that " it is calculated not only 



DISEASES OF THE URINARY ORGANS. 673 

to contract the muscular fibres of the prostate, but also primarily 
the capillary vessels, and secondarily, as a consequence of muscular 
contraction, its follicles and mucous glands, and thus the size as well 
as the nutrition of the glands would be diminished." He claimed 
to have seen the prostate decrease in size under the use of ergot. 
Sir Henry Thompson does not mention ergot as a remedy. Keyes 
says : 

" The radical treatment of enlarged prostate by medicine is in my 
opinion a delusion. The cases recorded prove nothing. Many a 
man has enlarged prostate and retention and uses a catheter for a 
longer or shorter period, and then under milk diet or improved health 
he recovers his expulsive power and abandons his catheter. I have 
several instances of this among my patients, none of whom took 
ergot, while I have given ergot in large and small doses to scores of 
people for months at a time, and have yet to see the first case that 
derived any advantage from the drug that I could appreciate. The 
same is my opinion of the interstitial injection of ergot or iodine into 
the prostate." 

Thompson is of the same opinion as to medicinal treatment. He 
writes : 

" I fear it must be acknowledged that no therapeutical agent is 
known which has the power of reducing an actual hypertrophy of the 
prostate." 

Dr. Bessey, of Toronto, Canada, in an excellent article on the 
surgical and medicinal treatment of enlarged prostate (" Hahne- 
mannian Monthly," 1892, p. 225) mentions ergot favorably. After 
quoting Atlee, he says : " As ergot is well known to be spasmodic 
in its action, and therefore only temporary in its effects, and as 
cohosh or cimicifuga possesses the power of producing tonic or per- 
manent contraction of involuntary muscle fibre, it suggested itself to 
my mind as the drug necessary to complete the good effects of the 
ergot in such cases, and I have been more than pleased with the 
results. My experience with these two agents has gone to show that 
they will accomplish the desired results, not only with mere hyper- 
trophy of the gland, but also in enlargement from myomatous growth, 
as in fibroid tumors of the uterus. By the combination of the cohosh 
the weakness of the sphincter and muscular walls of the bladder is 
greatly lessened, and the power of the bladder to expel its contents 

43 



674 THE PRACTICE OF MEDICINE. 

greatly augmented at the same time that the mechanical obstruction 
to catheterism is removed by the lessening of the size of the organ. 
My experience with the use of ergot alone was not completely satis- 
factory, as the symptoms after a time returned ; but since using the 
combination of the two drugs, ergot and cohosh, I have had no com- 
plaints, and the number of old men who have been able to drop the 
use of the catheter, after having been constantly dependent upon its 
frequent use for years, has been surprising, while the expressions of 
their gratitude is music to our ears." 

Dr. Bessey's use of cimicifuga in enlarged prostate is new. It 
is selected by him purely upon physiological data, it having no symp- 
toms to indicate it for this disease. It is said that thuja has the 
power of causing permanent contraction of involuntary muscular 
fibre. It has been used with apparent success in many cases of 
enlargement especially occurring after gonorrhoea. 

Lilienthal (" Therapeutics ") recommends for this condition aloe, 
cannabis, mercurius, nitric acid, pulsatilla, sulphur, and thuja. 
These are not homeopathic to the hypertrophy of old age, although 
they may be in the inflammatory enlargement occurring in young 
persons. Iodine has its advocates, but was most used when the 
prostate was supposed to be mainly a glanular organ. Dr. Safford, 
of London, recommended it in an " Essay on Diseases of the Pros- 
tate," and claimed to have cured eleven cases. But Sir Henry 
Thompson criticises these claims and finds them unwarranted. 

Lippe's recommendation of digitalis because it has some symp- 
tom of irritable bladder is not worthy serious consideration. A drug 
may have every symptom of a typical case of senile hypertrophy and 
be of no value in the treatment. 

Ustilago ought to be of value if ergot is. If, as it is claimed, 
hydrastis contracts blood-vessels leading to and in the uterus, and 
thus arrests the growth of fibroid tumors, then it ought to have a 
decided influence in reducing the size of those irregular nodulated 
prostates which contain fibroids. 

Conutine and hydrastinine are much more powerful than the 
crude drugs, and can be used effectually in smaller doses ; they might 
be advantageously injected into the substance of the prostate. I 
would advise the use of ergot, ustilago, hydrastis, and cimicifuga, by 
means of rectal suppositories containing a few grains of the solid 



DISEASES OF THE URINARY SYSTEM. 675 

extracts, and introduced at night. Sabal serrulata (saw palmetto) 
has within a few years been so highly praised and fulsomely adver- 
tised as a specific for enlarged prostate that it is time some serious 
inquiry should be made relating to its real value. My opinion is that 
it has no value in reducing the size of hypertrophied senile pros- 
tate. It has no physiological action that we know of upon muscu- 
lar tissue, striated or unstriated. It does stimulate, especially the 
generative glandular structures, and in massive doses may cause 
inflammation in such structures. Judging from its action in pharyn- 
gitis and other glandular mucous surfaces, I believe it capable of 
causing and curing mucous cystitis and urethrititis. It may have a 
specific affinity for the glandular elements of the prostate, the sem- 
inal vesicles, and the prostatic urethra. The reported cures seem to 
prove that here is its sphere of action. This would make it valu- 
able in acute, sub-acute, and chronic prostatitis with their attendant 
symptoms — a wide and useful sphere of action. I must caution 
against its use in large doses in all irritable or inflammatory condi- 
tions. It is only in atonic and torpid conditions of the genito-uri- 
nary organs that physiological doses are admissible. I do not know 
that muriate of barium has ever been used in hypertrophy of the 
prostate. Its curative power in various forms of sclerosis would 
warrant a trial in enlargement with sclerosis of that organ. 

In connection with any treatment adopted to reduce the size of 
the prostrate we should carefully select remedies for the reflex 
symptoms which arise from time to time. These symptoms are sin- 
gularly like the reflex symptoms which affect women who suffer from 
uterine disease and are generally relieved by the same remedies. 

When that condition known as catarrh of the bladder obtains, it 
must be treated topically and constitutionally according to the rules 
laid down in the treatment of that affection. 

Varicosis of the bladder and contiguous organs is nearly always 
present to a considerable degree in all cases of enlarged prostate. 
This condition adds greatly to the sufferings of the patient. It is 
possible to relieve this condition to some degree by the use of ham- 
amelis, collinsonia, carduus, and electricity. 

Dr. William Harvey King, of New York, in a very scientific 
and candid paper in the "Hahnemannian Monthly," 1892, writing of 
the value of electricity in enlarged prostate, says : " In order for us 



67G THE PRACTICE OF MEDICINE. 

to understand the condition which we are to relieve by this treat- 
ment, it is necessary to take a look at the pathology of the disease. 
When we bear in mind that the blood returning from the vesical 
veins has to pass through the plexus surrounding the prostate on its 
return to the general circulation, we can easily see how any enlarge- 
ment of that organ is liable to obstruct the venous circulation, and 
thus cause a venous congestion of the bladder- walls and membrane. 

" This venous congestion, together with the obstruction of the 
free flow of urine, thus causing greater labor for the bladder-wall, 
at first causes slight hypertrophy of the muscular fibre of that organ. 
This hypertrophy, however, never entirely compensates for the 
obstruction, and soon the walls of the bladder are in a state of atro- 
phy. As a consequence of this, mucus is thrown off, which makes 
the obstruction still more complete." 

"Finally the bladder is incapable of completely emptying itself. 
A sediment is left, the carbonate of ammonia is liberated, setting up 
a cystitis which, if the inflammation is allowed to go on, will follow 
up the ureters and produce a pyelitis. During all this time reten- 
tion is usually a marked symptom. 

"Now, the treatment which we are giving (the galvanic current), 
if administered in the early stages, while it does not remove the 
enlarged prostate, stimulates the walls of the veins, improving the 
circulation and removing the venous congestion of the bladder. It 
also stimulates the atonic bladder- walls, so that it can overcome to 
a great degree the obstruction, thus leaving less residual urine and 
lessening the liability of general cystitis. I have seen this treatment 
alone in the early stages of an hypertrophical prostate reduce the 
mucus so that it was only noticeable by carefully looking for it when, 
before the treatment, it left deposits covering the entire bottom of a 
chamber, and it also decreased the frequency of urination from one 
to three hours." 

I refer the reader to this article for the explicit direction for us- 
ing the galvanic current. 

ATROPHY OF THE PROSTATE. 
It seems to me that medical writers dismiss this disease with too 
much indifference. The following from Keyes will show how it is 
generally mentioned : 



DISEASES OF THE URINARY SYSTEM. 677 

" Atrophy of the prostate is rare, but it is occasionally encoun- 
tered. Among the recognized causes may be mentioned the atrophy 
of old age, coinciding with general atrophy of the rest of the body. 
Here the glandular rather than the muscular constituent disappears. 
Thompson, in his admirable monograph, which obtained the Jack- 
sonian prize in 1860, has, by laborious investigations, established 
the fact that the prostate does not necessarily atrophy. As a rule* 
it continues about the normal size, but it may occasionally atrophy, 
physiologically, like other structures in old age, just as it may, and 
often does (pathologically), hypertrophy. 

"Atrophy of the prostate, during general wasting diseases, espe- 
cially phthisis, has been noted. Pressure from a tumor, or cyst, or 
stone, within or near the prostate, may cause its atrophy, as may 
also the constant pressure of urine behind a tight stricture. Atro- 
phy, after double castration, is possible. Atrophy of the prostate 
has no symptoms except, possibly, lack of force in the ejection of 
semen. It is an unimportant affection, and has no direct treatment. 
If the cause can be discovered and removed (pressure), the ten- 
dency to atrophy may be overcome." 

Treatment. — While admitting that true senile atrophy of the 
glandular elements is incurable, i. e., that they cannot be restored, 
it may be possible that the natural physiological stimuli of those ele- 
ments, if properly applied, might ward off premature atrophy or at 
least retard it. After exhausting diseases both the muscular and 
glandular elements tend to atrophy. Here the same natural stimuli 
may be of value. Electricity ought to be of value if applied by an 
expert. 

Of the medicinal stimuli of the glandular elements — aurum, 
kava kava, eryngium aquaticum, phosphorus, damiana, sabal serru- 
lata, and thuja are the most useful. They should be used in small 
but material doses, not enough to cause unnatural excitement, or 
secondary effects. 

Those drugs which will depress the functions of the glandular 
elements are primarily homeopathic to atrophy. Conium 5 caladium, 
salix niger, lycopodium, nuphar, agnus castus, barium, and a few 
others are primarily indicated in minute doses, 

If atrophy of the muscular elements result from exhausting dis- 
eases, I do not see why the general nutritive-reconstructive remedies 



678 THE PRACTICE OF MEDICINE. 

should not restore its size. Sir Henry Thompson says : " What is 
the precise physiological action by which atrophy is determined? 
Is it some active process of absorption, removing the constructive ele- 
ments of the prostate, in the same manner, but more rapidly, than 
that ordinary process which results from the effete tissues through- 
out the whole body, in order that they may be, as constantly and 
gradually, replaced by new material ? I think not, but believe it to 
be rather the result of failing power on the part of the body to 
replace, by new material, the effete tissues removed by the natural 
process of absorption. It is not that the process of degradation is 
much more rapid, but that the powers of supply and reformation are 
less vigorous than heretofore. When the resources of the body are 
inadequate to supply the plastic material and the formative power, 
in an equal ratio with the expenditure, general atrophy must result." 

In such a condition described above, in addition to good food, 
pure air, and judicious exercise, I would advise the organic hypophos- 
phites (lime and soda) with iron, strychnine, and saw palmetto ; or 
phosphoric acid with hydrastis. These restoratives of the tone of 
the nervous and assimilative organs ought to bring back to a nor- 
mal condition a recent atrophy of both structural elements of the 
prostate. Phospho-albumen ought to be tried. 

Dr. W. H. King, in the " Hahnemannian Monthly," 1892, gives 
the following case, which probably was due to atrophy, in which elec- 
tricity appeared to cure. " Atrophy of the prostate," he observes, 
" is a very rare disease and one which I am not sure that I have ever 
treated. When we come to consider that the prostate is principally 
a muscle, the glandular portion only occupying an insignificant part, 
and that this muscular tissue is in structure analogous to the mus- 
cular tissue of the uterus, we might, considering the number of cases 
of atrophy of the uterus that have been improved by the use of elec- 
tricity, conclude that benefit would occur for a similar condition in 
the prostate, providing, of course, that the cause of the atrophy is 
removed. Some years ago I treated a case which was diagnosed by 
a physician other than myself as atrophy of the prostate. The patient 
was a man of about forty years of age, and had had stone in the 
bladder which had been crushed by a lithotrite. Sometime before 
the operation he noticed, in having sexual intercourse, that the semen 
would not come out in jets as it had formerly done, but would drib- 



DISEASES OF THE URINARY SYSTEM. 679 

ble out and continue after he had withdrawn. After the operation 
with the lithotrite it was found that this condition did not improve 
as it was thought it would, and the diagnosis of atrophy of the pros- 
tate was made and the patient sent to me for electrical treatment. 
He was given three treatments a week, varying from ten to fifteen 
minutes in duration. The faradic battery was used. One electrode 
was introduced into the rectum and carried up to the prostate, the 
other, a flexible hand-electrode, was pressed well forward on the per- 
ineum. The patient showed signs of improvement after the second 
week's treatment, and in nine weeks he had recovered to such an 
extent that the semen was all ejected before the penis was withdrawn. 
He considered himself cured and discontinued treatment. This case 
occurred in the early years of my practice, and I did not doubt at the 
time that I had in twenty-seven treatments cured a case of atrophy 
of the prostate gland ; but from examination made at the time, and 
with more mature experience, I now have doubts regarding the accu- 
racy of the diagnosis ; but still it might have been a case of atrophy 
of the prostate." 



CHAPTER VIII. 
DISEASES OF THE CIRCULATOHY SYSTEM 



It is not my intention to write a complete section on the diseases 
of the heart. I refer the reader to my " Lectures on Diseases 
of the Heart," the last edition of which has lately been published. 
I shall content myself with some general observations on inflamma- 
tions of that organ and their treatment; several chapters on the 
pulse ; and some of the more important diseases of the great blood- 
vessels. Within a few years our knowledge of the pathology of dis- 
eases of the heart and circulatory system has changed and greatly 
advanced, and the chief motive of the following articles is to pre- 
sent the newest investigations and their influence on the treatment 
of cardiac affections. 



INFLAMMATIONS OF THE HEART. 

(1) Pericarditis ; (2) Endocarditis ; (3) Myocarditis. 

I have grouped all three of the above inflammatory diseases of 
the heart together, for the reason that they generally have a com- 
mon cause and their essential treatment is the same. 

Idiopathic inflammations of the heart are very rare (Metch- 
kinoff says there is no such condition as idiopathic inflammation) ; 
they are usually secondary to four diseases, which I will name in the 
order of their importance : (1) Rheumatism, (2) Bright's disease, 
(3) scarlet fever, (4) chorea. It is the generally accepted belief 
that rheumatism is the cause of the majority of all cardiac inflam- 
mations. It must be understood that they are not due to a metas- 
tasis of rheumatic inflammations, because they often appear before 
any joint or other tissue is affected. Endocarditis and the others 
are often essentially rheumatic ; they are a part of that general 
blood contamination which we call the rheumatic state. 



DISEASES OF THE HEART. 681 

Bright's disease, while often a consequence, as often causes inflam- 
mation of the heart, because it originates septic poisons which are 
carried by the blood to the heart and irritate its tissue-cells, until 
inflammation — which is an effort to rid the tissues of poisonous 
matters — sets in and produces degenerative changes. 

Scarlet fever causes cardiac inflammations in the same manner. 

Chorea is supposed to be intimately connected with endocarditis, 
but this connection has never been fully explained. The essential 
cause of chorea may be in the central nervous system, and so may 
the endocarditis and myocarditis which often accompany it ; or it 
may be of microbic origin. 

The treatment of these inflammations should not be altogether 
symptomatic. If we follow such a line we shall fail to arrest the 
destructive processes. We must combat the poison which exists in 
the blood and tissues, and if possible prevent their formation and 
deposition. 

If the cause of the inflammation is the rheumatic poison (uric 
acid), the alkalies must be used for the purpose of rendering the 
blood so alkaline that the urates will not be deposited in the tissues 
of the heart, causing those vegetations on the valves which interfere 
with their normal action. Small doses of the acetate, nitrate, or 
lithate of potassium seem the best adapted to this condition. To 
these chemical agents we can add such medicines as bryonia, col- 
chicum, cimicifuga, manaca, rhus tox., and others. Then there are 
agents like salicylate of sodium, salicin, salol, and salophen, which 
seem to have a double action, partly chemical and partly medicinal. 
It should be remembered, however, that all these agents in large 
doses tend to weaken the muscular structure of the heart, which is a 
result to be avoided. The use of these drugs in massive doses by 
the old school is pernicious and unnecessary. Instead of giving the 
salts of potassium, the salicylates, etc., in twenty or thirty-grain doses, 
give them in doses of one-tenth or one grain frequently repeated, 
and we shall get their beneficial effects only. The same can be said 
of the use of the vegetable medicines above mentioned. Small doses 
of bryonia and the others do much better service than large ones. 
When there is high fever, with increased and too powerful action of 
the heart, aconite, veratrum viride, and colchicum in small doses 
(lx, in one to five-drop doses) frequently repeated will soon subdue 



682 THE PRACTICE OF MEDICINE. 

the abnormal action and reduce the temperature. The use of the 
so-called antipyretics, such as antipyrin, is injurious and unneces- 
sary. The injury done by high temperature has been greatly exag- 
gerated. Drugs may reduce the heat of the body, but they do it at 
the expense of the vitality of the muscular structure of the heart. 
The use of cold water or ice over the heart is utterly without reason, 
as much so as copious blood-letting. The action of aconite and vera- 
trum viride in inflammation or hyperpyexia is in no sense homeo- 
pathic. They cannot cause either ; their action is physiological and 
mechanical ; as much so as putting the brakes to the wheels of a car- 
riage or railroad coaches. Bryonia, spigelia, and colchicum do act 
homeopathically in such cases because they are capable of causing 
carditis. 

As soon as we find that the above medicines are slowing the 
action of the heart, and lowering its impulse to near the normal, 
they should be suspended, for on no account should we weaken the 
impulse of the heart below its normal, for if we do we retard the 
process of compensation — nature's method of repairing the injury. 

The primary action of all the above mentioned agents is to weaken 
the heart. They are therefore homeopathic to that condition. But 
I have never been confident that they will restore a weak heart to its 
normal strength. It seems to me that here, again, we must resort 
to physiological remedies. It is a delicate question, and requires 
good diagnostic acumen to decide just when to commence the use of 
digitalis, convallaria, cactus, or strychnine. If we use them too soon 
we tire out the heart by over-stimulation. We should wait until the 
soft compressible pulse, irregular or intermittent, the weak impulse 
of the heart, and the general loss of normal tension in the arteries, 
with fullness of the venous system, show that the heart's action is 
failing in force. When this occurs do not hesitate to give digitalis 
and nux vomica, or digitalis and strychnine, or cactus with strych- 
nine, until we are convinced that we have arrested the tendency to 
cardiac failure. The doses of all the above except strychnine should 
be from one to five drops of the tincture or lx every four or six 
hours ; of strychnine the 100th or 50th of a grain at the same inter- 
vals. This is a general rule and can be modified according to the 
age, susceptibility, or idiosyncrasy of the individual patient. Bry- 
onia, manaca, spigelia, rhus tox., cimicifuga, or cactus, for the inflam- 



DISEASES OF THE HEART. 683 

iiiation, should be selected from the subjective symptoms which they 
cause when given in health, and not from objective or general indi- 
cations. 



CHRONIC VALVULAR DISEASE. 

I shall give only a brief general statement of valvular diseases and 
a definition of each, with the general principle of their treatment. 
In my " Lectures on Diseases of the Heart " will be found their 
complete etiology and diagnosis. 

At a late meeting of the British Medical Association Dr. David 
Drummond, one of its most eminent members, speaking of the caus- 
ation of cardiac diseases, says : 

" The study of cardiac lesions throws into relief the importance 
of tracing diseases to their true causes. They are all referable to 
primary conditions — rheumatism, gout, specific fevers, tuberculosis, 
sepsis, alcoholic excess, syphilis, etc., which are singularly fruitful 
in morbid products. These conditions constitute a formidable list, to 
which we are constantly adding, and each is responsible for heart affec- 
tions having more or less characteristic, clinical, and pathological fea- 
tures. The immense importance of investigating cardiac diseases upon 
the basis of their antecedent and underlying morbid states cannot be 
-over-estimated, for the treatment and prognosis depend largely upon 
the particular agent at work. It has been the habit of our schools 
to attach too much value to the diagnosis of the particular valve- 
lesion, and too little to its cause. Thus, for example, we content 
ourselves with the shallow and often unimportant observation that this 
or that case is one of mitral regurgitation or double aortic disease, 
forgetful that what is of paramount importance is not only the pri- 
mary reason for the existence of the lesion, but also the cause upon 
which the symptoms belonging to any subsequent attack of cardiac 
failure may depend. Thus the inquiry would necessarily embrace 
the questions in the case of toxsemic lesions, gouty, rheumatic, alco- 
holic, etc., is the poison still circulating? and what is the prospect 
of its return ? Difficult, and at present more or less problematical, 
are these questions, but to them we must direct our attention before 
we can hope to prognose and treat heart disease successfully. Would 
.a substantial reduction in the number of chronic heart cases, as the 



684 THE PRACTICE OF MEDICINE. 

result of the recognition of the fact that many are due to curable 
and preventable causes which an early and successful treatment might 
reasonably be expected to subdue, be a dream too visionary for us 
to indulge in ? I think not ; but assuredly until we fully appreciate 
the causes, a dream it will remain." 

This reads as if it might have been written by Samuel Hahne- 
mann. It will remind the reader of his teachings in the " Organon," 
and his directions for examining the patient. He taught the import- 
ance of investigating the remote and underlying causes of organic 
diseases, which we will do well not to forget. 



AORTIC INCOMPETENCY. 

This is the best defined and most easily discovered of all the valv- 
ular lesions. It is commonly designated as Corrigan's disease, named 
after the distinguished physician who first carefully studied it. 
Incompetency of the aortic valves arises either from inability of the 
valve segments to close an abnormally large orifice, or from disease 
of the ligaments of the valves themselves. These pathological con- 
ditions may be caused by congenital malformation, a fusion of the 
two segments, acute endocarditis, a sclerosis of the segments result- 
ing in a curling of the edge which lessens the working surface of 
the valves, or insufficiency may be induced by rupture of a segment 
from excessive strain during heavy lifting. The direct effect of 
aortic insufficiency is the regurgitation of blood from the artery into 
the ventricle, causing an over-distention of that cavity and a reduc- 
tion of the blood column, i. e., a relative anaemia of the arterial tree. 
Dilatation of the ventricle occurs, and finally hypertrophy. In this 
way the valve defect is compensated, and a larger amount of blood 
is propelled into the arterial system. When this occurs the regurgita- 
tion of a certain amount of blood during diastole does not for a time 
seriously impair the nutrition of the peripheral part. In this valve 
lesion dilatation and hypertrophy attain their extreme limit. The 
enlarged heart may reach the enormous weight of over forty ounces. 

Diagnosis and Symptoms. — Inspection shows a wide and for- 
cible area of cardiac impulse, with the apex beat in the sixth or sev- 
enth interspace, and as far out as the anterior axillary line. A 



DISEASES OF THE HEART. 685 

thrill, diastolic in tone, is often felt. The impulse is strong and 
heaving, except in extreme dilatation, when it is wavy and indefinite. 
Percussion shows a greater increase in the area of heart dullness 
than is followed in any other valvular lesion. On auscultation a 
murmur is heard during diastole in the second right interspace, 
extending with intensity downward towards the ensiform cartilage. 
This sound is a soft, long-drawn-out bruit, and is of all cardiac mur- 
murs the most reliable. This sound is, however, often regarded as 
indicating stenosis, whereas in aortic insufficiency there is no mate- 
rial narrowing, the murmur being produced by a roughening of the 
segments. An examination of the arteries in this lesion is of great 
importance, as visible pulsations of the peripheral vessels is more 
commonly seen in aortic insufficiency than in any other condition. 
The carotids may be seen to throb forcibly, the temporals to dilate, 
and the brachials and radials to expand with each heart-beat ; with 
the opthalmoscope the retinal arteries are seen to pulsate. In the 
throat the throbbing carotids may lead to a diagnosis of aneurism. 
The abdominal aorta may lift the epigastrium with each systole. 
Sometimes the face and hands will blush with each systole. The 
pulse is designated as " water-hammer " or " Corrigan's pulse "; the 
pulse-wave strikes the finger forcibly with a quick, jerking impulse, 
and immediately recedes or collapses. 

Prognosis. — When compensation occurs it may last for years, 
the patient may not suffer any inconvenience, and the condition is 
often found accidentally. So long as the hypertrophy or thickening 
of the muscles just equalizes the valvular defect there may be no 
symptoms, and moderately heavy exercise may be taken without dis- 
comfort or distress about the heart. Pure aortic insufficiency is con- 
sistent with average health, but as soon as the compensation is dis- 
turbed by changes in other valves, or sclerosis of the arch or orifice 
of the coronary arteries, unpleasant symptoms will appear, such as 
headache, dizziness, flashes of light, faintness on rising quickly, pal- 
pitation and cardiac distress on slight exertion, and even pain of a 
dull, aching character in the region of the heart. The pain, how- 
ever, may be sharp and radiating, and is transmitted up the neck 
and down the arms, particularly the left. Attacks of true angina 
pectoris are more common in this lesion than in any other. As the 
rupture of compensation increases, more serious symptoms set in, at 



686 THE PRACTICE OF MEDICINE. 

first shortness of breath and oedema of the feet, then nocturnal 
dyspnoea so severe that the patient has to sleep with the head high 
or sitting in a chair. Cough, haemoptysis, distressing dreams, hema- 
turia, and finally general anasarca, with emboli and a sudden ending 
of life, will close the scene. The mental symptoms are important. 
Suicidal mania, great irritability of temper, and finally uraemic deli- 
rium are often met with. 

Treatment. — So long as the patient does not complain of any no- 
table general or local symptoms the treatment need not be medicinal, 
for no medicine can change the condition of the valve. I know it is 
claimed by Grauvogl and a few others that spongia, iodine, calcarea, 
and aurum, in high dilution, may have a curative effect, but I have 
never verified their claims ; yet, as these medicines in minute doses 
can do no harm there is no objection to their use. 

The patient should be warned against severe exercise, or any 
unusual exertion ; also against heavy meals, and the use of alcohol. 

When, however, the balance of compensation is lost, medicinal 
treatment should be commenced. The remedy may be selected 
according to the law of similia, but it must not be forgotten that not 
only should the symptoms of the drug correspond with those of the 
patient, but the drug selected should be one possessing a known 
affinity for the heart. A non-cardiac drug may palliate some reflex 
symptoms, but does not possess curative value. The medicines which 
seem to be homeopathic to aortic incompetency are aconite, agaricus, 
belladonna, glonoine, aurum, baryta, iodine, spongia, and spigelia, 
used in the 3d dilution and upwards. 

The physiological remedies, or those which are most capable of 
arresting or preventing a failure of compensation, are convallaria, 
digitalis, adonis, oleander, and sparteine. Some authorities have 
objected to the use of digitalis in this lesion, but it can be used with 
great benefit. Osier, whose experience enables him to speak with 
decision, says : " On theoretical grounds it has been urged that the 
use of digitalis is not so advantageous in aortic insufficiency, since 
it prolongs the diastole and leads to greater distension. Practically, 
however, this need not be considered, as when given with care digi- 
talis is just as serviceable in this as in any other condition associated 
with progressive dilatation." The fact is that great injury will 



DISEASES OF THE HEART. 687 

result from its use if given while the heart is capable of maintaining' 
the balance of competency. But when the signs of weakening 
appear, then small doses (fifteen or twenty drops of the lx or three 
to five drops of the tincture) every four or six hours will aid in the 
arrest of the failure. My main objection to digitalis is, that it les- 
sens the calibre of the arteries, and may in that way subject the 
heart to an over-strain. My practice is to begin with convallaria or 
coronilla, which do not contract the arteries much, while they give 
the heart-muscle greater tonicity. The dose of both varies from ten 
drops of the lx to ten of the tincture every three or six hours. Cac- 
tus is too much like digitalis to be used in large doses, but the dilu- 
tions are valuable as a palliative to many symptoms, especially to 
the angina pectoris which so often attends this lesion. 

Jamaica dogwood (piscidia) is often very useful for symptoms 
simulating angina pectoris ; a single dose of twenty to thirty drops of 
the tincture ; or lx frequently repeated. 

For the relief of the mental symptoms, aurum and hyoscyamus 
are invaluable. (I value hyoscine hydrobromate higher than the tinct- 
ure. Its calming influence over the brain is superior to any other 
drug when given in doses of a grain or two of the 3x). 

In no valvular lesion is bodily and mental rest so useful to restore 
broken compensation. 

AORTIC STENOSIS. 

In stenosis there is more or less narrowing or stricture of the aortic 
orifice, which may be caused by an adhesion between segments so ine- 
lastic that they are not pressed back against the aortic walls during the 
systole. Sometimes the valve segments are thin, sometimes thick and 
rigid, and have a cartilaginous hardness and present stiff, calcified 
masses, obstructing the orifice. 

Aortic stenosis is not always found to exist alone ; in a majority 
of cases there is some leakage from inefficiency ; as in the last men- 
tioned lesion, there occurs a dilatation of the left ventricle, and some- 
times forms that lesion called concentric hypertrophy, in which, with- 
out much, if any, enlargement of the cavity, the walls are greatly 
thickened, in contradistinction to the so-called concentric hypertrophy 



688 THE PRACTICE OF MEDICINE. 

in which the chamber is greatly dilated as well as hypertrophied. 
We do not find the same condition of the arteries as in insufficiency, 
for their walls have not to withstand the impulse of a greatly increased 
pulse-wave with each systole. On the contrary the amount of blood 
propelled through the orifice may be smaller than normal ; when, how- 
ever, compensation is fully established the pulse-wave may be of 
medium volume. 

Symptoms. — Auscultation may not reveal any increased area of 
cardiac impulse. Even when the apex-beat is visible, it may be feeble 
and indefinite. Palpation may reveal a thrill at the base of the 
heart in the region of the aorta. This thrill is of greater intensity 
than in any other condition. Auscultation reveals a systolic mur- 
mur of greatest intensity at the aortic cartilage, and extending into 
the great vessels, but this murmur does not always mean a stenosis, 
but may be caused by roughening of the valves or the surface of the 
aorta, or it may be haemic. When the compensation is complete the 
murmur is harsh and loud ; when it fails the murmur is soft and 
distant. 

Diagnosis. — When we find an intensely rough or musical murmur 
of greatest intensity at the aortic region, with signs of enlargement 
of the left ventricle, a thrill, and a hard slow pulse of moderate 
volume and fairly good tension, aortic stenosis is probably present. 

Treatment. — The principal medicines indicated in this condition 
before compensation has obtained, and after it has begun to fail, are 
aconite, veratrum album, veratrum viride, iodide of arsenicum, phos- 
phorus, tartar emetic, cactus, nux vomica, arnica, and erythrophleum. 
If there is undue arterial tension, as there often is in this lesion, we 
must resort to iodide of potassium, veratrum viride, and glonoine. 
When the compensation is broken we have the same results as in 
aortic insufficiency, namely, dropsy, dyspnoea, congestion, and oedema 
of the lungs, congestion of the kidneys with rapid degeneration ; and 
the same remedies are required for the failing heart and general ven- 
ous stasis. The dyspnoea in this disease is peculiarly distressing. 
I have found quebracho to give more relief than any other remedy. 
In one case a patient was enabled to walk and lie down with com- 
fort when taking a two grain pill of the solid extract three or four 
times a day. In another case fifteen drops of grindelia robusta every 
three hours gave great relief. 



DISEASES OF THE HEART. 689 



MITRAL STENOSIS. 



This lesion is usually the result of valvular endocarditis. It can 
occur early in life, and more often in girls than in boys. It is certainly 
more commonly found in women than men. Rheumatism for some 
reason occurs more commonly in girls than boys, and inflammation 
of the mitral valve is the most common lesion in rheumatism. 
Chorea, according to Bartholow, has an important influence, but 
whether it is a cause or not has not been fully proven. Osier says 
that of 110 cases of chorea which he examined two years after the 
attack, 54 had signs of organic heart disease and 17 had mitral sten- 
osis. Of 25 cases of chorea which I have treated, 23 had signs of 
mitral disease. I have found it in anaemia and chlorosis, and have 
known it to result from scarlatina and pertussis. 

Stenosis of this valve results from narrowing aud thickening of 
the tissues of the ring or valve-segments. The chordae tendonae may 
become contracted. Cases have been described by Corrigan where 
the orifice was reduced to a mere chink or slit Q c button-hole con- 
traction "). Usually, however, the orifice will admit the tip of the 
index finger. In mitral stenosis the heart is not greatly enlarged, 
rarely weighing more than fifteen ounces. The left ventricle is 
usually small, while the right is enlarged. The secondary alterna- 
tions are important. The left auricle is dilated and its walls become 
three or four times as thick as normal. Eventually the right ven- 
tricle becomes dilated and hypertrophied. 

Symptoms. — In children inspection reveals a protrusion of the 
lower sternum and the fifth and sixth costal cartilages caused by 
hypertrophy of the left ventricle. The apex is not removed far 
beyond the nipple, and the chief impulse is over the lower ster- 
num. 

Palpation reveals a well-defined thrill in the fourth or fifth inter- 
space within the nipple line. Its quality is rough and grating, and 
terminates in a sharp, sudden shock synchronous with the impulse. 
This is a sure indication of mitral stenosis. 

Percussion shows an increase of cardiac dullness to the right of 
the sternum and along its left margin. 

Auscultation shows a rough vibratory murmur in the mitral area 
on the inner side of the apex-beat which terminates abruptly in the 



44 



690 THE PRACTICE OF MEDICINE. 

first sound. This is a positive indication of mitral narrowing. (For 
the finer physical signs consult my " Lectures on Diseases of the 
Heart.") So long as compensation exists persons with this lesion 
will present no unpleasant symptoms, but when it is broken there 
will be great shortness of breath on ascending stairs or hills. If a 
new attack of endocarditis then occurs vegetations may be whipped 
off into the circulation, blocking a cerebral vessel and causing hemi- 
plegia or aphasia. 

Failure of compensation will, according to Broadbent, cause rapid 
and irregular action of the heart, dyspnoea, pulmonary engorgement, 
and haemoptysis. If pneumonia occurs it is generally fatal. Dropsy 
does not usually occur from mitral stenosis. The liver may become 
greatly enlarged, and ascites is common. True insufficiency of this 
valve is very rare, although in stenosis there is occasionally some 
leaking. 

Treatment. — After rheumatic attacks, compensation can be has- 
tened by the use of nux vomica, digitalis, cactus, and rest. When 
compensation obtains no medicine is needed. The patient must 
avoid all extreme exertions, wear woolen clothing, and be careful of 
exposure to cold, damp air. The above medicines are also useful 
when compensation fails, and they can be aided by other medicines, 
among which are carduus, euonymin, agaricus, and chelidonium for 
the enlargement of the liver ; phosphorus, lycopus, tartar emetic, and 
sanguinaria when pulmonary engorgement or haemoptysis occurs. 
If ascites sets in, apocynum and digitalis are the best remedies. 



TRICUSPID AND PULMONARY VALVE LESION. 

These lesions will not be treated of in this work. I refer the reader 
to the works of Flint and Bramwell, and to my " Lectures on Dis- 
eases of the Heart." 



HYPERTROPHY AND DILATATION. 

As hypertrophy and dilatation are both due to valvular diseases, 
myocarditis, or arterio-sclerosis, all of which have already been dis- 
cussed and their treatment outlined, I shall not enter into a further 



DISEASES OF THE HEART. 691 

consideration of them, but refer to the above authorities. Even 
when caused by heart strain or alcohol, the treatment has been 
already outlined. 



ESSENTIAL PAROXYSMAL TACHYCARDIA. 

Definition. — Paroxysms of rapid action of the heart with equally 
rapid pulse. 

As described by Bouveret, of Lyons, France, this affection seems 
to be a pure neurosis. In his description of the paroxysms Bouveret 
divides them into two classes, according to their greater or less dura- 
tion, because of the pathological consequences which ensue if they 
are prolonged beyond a certain period. If they last more than four 
or five days, we see secondary disturbances of the circulation and 
respiration, due to the rapid weakening of the heart, its dilatation, 
and the incomplete emptying of its cavities. 

In the short attack there is nothing noteworthy except the extreme 
rapidity of the heart's action. This rapidity may attain 250 or even 
300 pulsations a minute. It is very like that produced by section 
of the pneumogastrics in animals. The pulse is usually regular ; 
occasionally there are periods of irregularity. It is often not per- 
ceptible at the wrist, but is to be felt in the carotids and femorals. 
The second pulmonic sound is accentuated, showing increased ten- 
sion in the pulmonary artery. Sometimes there are prodromata, 
such as dizziness, or a sense of constriction at the throat or epigas- 
trium. Generally the beginning is sudden, without warning. Often 
there is no cause for the attack ; at other times it follows some 
strong mental emotion or physical fatigue or effort, and such causes 
are especially efficient during convalescence from a previous attack. 
The face is usually very pale throughout the paroxysm. The pupils 
are normal, and there are, as a rule, no vaso-motor disturbances. 
There may be moderate dyspnoea ; anorexia and constipation are 
usually present, and almost complete insomnia. There is marked 
diminution of the urinary secretion, but no albuminuria and no fever. 
In some cases the temperature is below normal. 

The subjective sensations are variable ; sometimes epigastric op- 
pression, pain at the prsecordia, numbness of the left arm or general 
chilliness. The attack ends as abruptly as it began, the pulse drop- 



692 THE PRACTICE OF MEDICINE. 

ping suddenly from 200 or more to 72 beats a minute. Huppert 
noted the change of the pulse in his patient from a vague undula- 
tion to strong, regular, slow, equal pulsations. The short attack 
leaves but little prostration afterward. The long paroxysm, how- 
ever, is much more serious, because of the secondary respiratory and 
circulatory disturbances. There is extreme cardiac distension, as 
shown by the dullness. In one case of Bouveret's the dullness 
extended from the upper border of the third rib to two inches below 
and outside of the nipple, and from an inch to the right of the ster- 
num to one-half inch beyond the left mammary line. Sometimes 
there is a soft systolic murmur during the paroxysm or during the 
convalescence, disappearing later. The stasis in the left ventricle 
and auricle and pulmonary veins causes congestion and oedema of 
the lungs. The patient has cough, dyspnoea, and bloody expectora- 
tion. Sonorous and sibilant rales and friction sounds are to be heard. 
In some cases there is pleurisy with effusion. The temperature may 
rise three or four degrees, owing to the pulmonic process. There is 
marked cyanosis of lips and cheeks, and swelling and pulsation of 
the jugulars. There may be agitation and restlessness at night, 
unpleasant dreams, and even delirium. The cerebral disturbances 
are probably due to the arterial ischsemia and venous stasis pro- 
longed for several days. Swelling of the liver and spleen are noted, 
also ascites and oedema of the ankles. The urine is diminished 
and high-colored, and usually contains albumen and blood-globules. 
When the attack ceases the urine increases in amount, and the albu- 
men and blood disappear. 

In place of constipation there is diarrhoea as a result of the 
venous stasis in the intestinal mucous membrane. The subjective 
sensations are usually the same as in short attacks. In one case, 
toward the end of a paroxysm which had lasted three weeks, and 
which terminated fatally, the praecordial pain was so intense as to 
recall that of angina pectoris. Bouveret attributes this pain to the 
ischaemia of the heart-muscle, due to the same lack of tension in the 
coronary arteries that is found in the peripheral vessels. Some pa- 
tients have fainting spells and syncope, especially if they attempt to 
rise from the recumbent position. At the end of the paroxysm the 
secondary symptoms disappear gradually. Several days elapse before 
the lung clears up. The urinary symptoms cease at once. The heart 



DISEASES OF THE HEART. 693 

remains irritable during the first few days of convalescence, and a 
return of the paroxysm may be produced by a very slight cause, such 
as sitting up in bed. The extreme cardiac distension, however, dis- 
appears in a few hours. The paroxysms ended fatally in eight of 
the twenty-seven cases, twice by syncope, twice by a systolic collapse, 
and in the other cases by pulmonary congestion or intestinal hem- 
orrhage. 

Etiology. — In discussing the etiology of the disease, Bouveret 
draws attention to the entire absence of hysteria or neurasthenia in 
the cases collected by him, nor was there any hereditary neurotic 
tendency. In most of the other cases reported it is also stated that 
there was no evidence of nervous predisposition. 

Faisan's two cases, however, were those of mother and daughter. 
My patient was of nervous temperament and had an epileptic son. 

The disease is not often observed in children. In Brieger's case 
the paroxysm began when the patient was nine years old. In the 
other cases the age at onset varied from nineteen to fifty-two years. 
The influence of sex is not marked ; of twenty-five cases in which the 
sex is noted, eleven were males and fourteen females. Over-fatigue, 
either mental or physical, seems to be the chief cause of the affec- 
tion. Excessive smoking is also an important factor, and the drink- 
ing of strong coffee. In Gerhardt's case the attacks came on after 
long-continued literary work and immoderate smoking. Bouveret's 
first patient, a professor, was accustomed to read and study late at 
night, smoking at the same time. He also drank considerable coffee. 
In one case the paroxysm was caused by a fright two or three days 
after confinement. In my patient a fright seemed to be the excit- 
ing cause. In Sollier's case the attacks occurred whenever the 
patient, a lacemaker, had been greatly vexed or annoyed in her busi- 
ness. 

Pathology. — The pathology of essential paroxysmal tachycardia 
is still undetermined, and is perhaps not the same in all the cases. 
The majority of observers believe that we have to do with a pare 
neurosis, a temporary disturbance of the motor innervation of the 
heart. Such a disturbance might be caused in three ways : by exci- 
tation of the sympathetic, by a modification of the activity of the 
intra-cardiac ganglia, or by a temporary paresis of the vagus. Dr. 
Wood considers the tachycardia to be due to a discharge of nerve 



694 THE PRACTICE OF MEDICINE. 

force and not to a paralysis of inhibition, comparing it to the epilep- 
tic paroxysm, which, he holds, is the result of a discharging lesion, 
and not a temporary palsy. The tachycardiac paroxysm, in his opin- 
ion, is likewise due to a discharging lesion affecting the centres of 
the accelerator nerve of the heart, the sympathetic. 

Nothnagel, on the other hand, employs the same illustration to 
support the theory of a paresis of the vagus. He sees in the loss of 
consciousness which accompanies the epileptic convulsion a sudden 
spontaneous cessation of functional activity on the part of central 
nervous organs, a sort of torpor or temporary paralysis. In the same 
manner we can conceive, he thinks, of a temporary torpor of the car- 
diac centres of the vagus in the medulla. The respiratory and gas- 
tric centres are not affected, nor is the trunk of the nerve itself. It 
has already been stated, in the description of the paroxysms, that 
there are, as a rule, no vaso-motor symptoms nor changes in the 
pupils. This fact is opposed to the idea of sympathetic irritation. 
What part is borne by the intra-cardiac ganglia in the nervous dis- 
turbances it is difficult to say. It is not thought that they are ever 
the primary cause of the attacks. It seems probable, on a review of 
all the evidence, that in most cases there is paresis of the vagus, of 
central origin. In three cases there was evidently excitation of the 
sympathetic, as shown by the accompanying vaso-motor phenomena. 
It has been proved that only a very strong excitation can overcome 
the vagus tone, and hence inferred that the sympathetic cannot excite 
a very rapid action of the heart. The few cases in which it has 
caused marked tachycardia are to be explained by the fact that the 
vagus grows exhausted by prolonged sympathetic irritation, so that 
finally only the cardiac motors are active. The general conclusion is, 
then, that the affection is a bulbar neurosis, confined to the cardiac 
centres of the vagus in the medulla. 

Dr. Samuel West, however, does not concur in this opinion. 
While agreeing that the tachycardia is of nervous origin, he believes 
that the nervous irritability is due to organic disease of the heart, 
probably of the myocardium. He suggests that there is perhaps a 
chronic interstitial myocarditis, developing either spontaneously or 
consequent in some cases on past rheumatic pericarditis, or in others 
on syphilis, being thus related to fibroid disease of the heart. Let 
us see how Dr. West's theory is borne out by the four autopsies of 



DISEASES OF THE HEART. 695 

which we have record. I have already stated that the nervous sys- 
tem was normal throughout. In Sollier's case the heart also was pro- 
nounced free from disease, but unfortunately the myocardium was 
not examined. Hence this case is of no value on this point. Bris- 
towe states that in his case, also, the heart was normal in all respects, 
the muscular tissue included. But the autopsy was made four days 
after death, and the heart was in advanced state of decomposition. 
We can hardly, therefore, attach much weight to the evidence yielded 
by the microscope. 

We have left the cases of Brieger and Fraentzel, in both of which 
a careful examination of all the organs was made soon after death. 
The records of the autopsies are strikingly alike in the two cases, for 
in both there was an extensive development of fibrous tissue in the 
wall of the left ventricle, whereas the valves of the heart were abso- 
lutely normal. Brieger attributes the tachycardia in his case to 
vagus paresis combined with sympathetic irritation, and apparently 
attaches little importance to the post-mortem appearances. He 
expressly states that in his opinion the degenerative changes in the 
heart were of recent date and due to the long-continued irritation of 
the cardiac muscles. As the paroxysms had existed for twenty-four 
years in his case, such an explanation is at least plausible. 

Fraentzel's patient, however, had suffered from tachycardia for 
only three months before death, and yet the changes in the heart- 
muscle were most marked, as will be seen from the following extract 
from the report of the autopsy : " Left ventricle hypertrophied ; 
increase of connective tissue, thickest next to the endocardium ; pap- 
illary muscles and trabecule in left ventricle very thin and every- 
where infiltrated with newly-formed connective tissue ; foci or fatty 
degeneration in the connective tissue formation immediately beneath 
the endocardium of the ventricular septum ; entire endocardium of 
the left ventricle much thickened ; many trabecule have undergone 
fibroid degeneration." 

Fraentzel makes no comment whatever upon the findings of the 
autopsy, but simply states, in concluding his paper, that the pathol- 
ogy of the disease is still very obscure. It seems, then, that inter- 
stitial myocarditis was present in the only cases in which the mus- 
cular tissue of the heart was properly examined, thus confirming Dr. 
West's opinion that we should look to the myocardium for the cause 



696 THE PRACTICE OF MEDICINE. 

of the nervous irritation. But if it is proved that there is organic 
heart disease in some cases at least, why need we longer say that the 
tachycardia is of nervous origin ? 

Physiology has demonstrated that rhythmical contraction is a 
property inherent in the myocardium and not absolutely dependent 
on the nervous system. It is not necessary, therefore, in all cases to 
appeal to a disturbance of the cardiac ganglia or nerves to explain 
disturbances of the cardiac rhythm. A simple lesion of the cardiac 
muscle is capable of producing by itself all the symptoms of dis- 
turbed rhythm. We shall see later that the paroxysms in several 
cases were arrested by pressure upon the cervical pneumogastric. 
The fact that the intra-cardiac ganglia received and responded to 
this artificial stimulus is proof of their integrity, in those cases at 
least. The pathological evidence, as far as it goes, supports the 
theory that we are dealing with a cardiac and not a nervous disease* 
but the next autopsy may demolish this theory completely. It may 
be said also with truth that the clinical picture of the milder forms 
of tachycardia accords better with the assumption of a neurotic dis- 
turbance of the heart than with the presence of so formidable a dis- 
ease as myocarditis. In some cases the symptoms are absent for 
years, or may disappear apparently forever. But, in answer to this, 
we have the authority of Fagge that fibroid diseases of the heart 
sometimes give rise to no symptoms whatever. Huchard, also, states 
that sometimes at autopsies extensive disease of the cardiac muscular 
fibres is found which during life had caused no marked symptoms. 
In other cases apparently insufficient lesions had caused grave symp- 
toms. These discrepancies he explains by the existence in the heart, 
as in the brain, of regions that are tolerant or indifferent in regard 
to destructive lesions, and of other intolerant regions, the latter 
depending on the importance and the absence of anastomosis with 
an obliterated artery, and also depending on the function of the 
affected muscular fibres. The intolerant regions are especially the 
papillary muscles and the fibres in contact with the ganglia and the 
interventricular septum particularly, because on it depends the har- 
monious working of the two ventricles. This explanation of Huchard 
accords with the post-mortem appearances in Fraentzel's case. For, 
as you may remember, the papillary muscle and the ventricular sep- 
tum were both involved in the degenerative process, thus accounting 



DISEASES OF THE HEART. 697 

for the rapidly fatal ending. Perhaps in the milder cases, with 
infrequent paroxysms, the interstitial growth is situated in the more 
tolerant regions of the heart-muscle. However, as I have already 
intimated, two autopsies do not furnish a very secure foundation for 
a new theory, and it is probably wiser for the present to agree with 
Fraentzel that the pathology of the affection is still very obscure. 

Diagnosis. — A well-marked case of essential paroxysmal tachy- 
cardia can hardly be mistaken for any other disease. There is no 
exophthalmus nor any enlargement of the thyroid ; in Graves's dis- 
ease, also, the acceleration of the heart's action is continuous, and 
never attains two hundred beats a minute, and the pulse is always 
perceptible at the wrist. Organic lesions of the vagus cause perma- 
nent tachycardia ; they are accompanied, too, by respiratory and gas- 
tric disturbances. The disease does not last long, being soon fatal. 
Lesions of the pons or medulla would also give a constant accelera- 
tion of the pulse and be attended with motor or sensory disturbances, 
and very soon cause death. Angina pectoris is excluded by the ab- 
sence of the intense pain characteristic of that disease. In angina, 
also, the pulse does not attain such rapidity. Reflex tachycardia is 
more difficult to exclude, if there are present any gastric, uterine, or 
ovarian disturbances at the begiuning of the paroxysm. In the cases 
referred to above, the attacks occurred at a time when all the func- 
tions of the body were in perfect order. As to whether, in a given 
case, the symptoms are due to a paralysis of the vagus or to an excita- 
tion of the sympathetic, that is, as Fraentzel has said, only a matter 
of theoretical interest. Nothnagel gives the following points of dif- 
ferential diagnosis : If the pulse rate is very rapid, but the rhythm 
is even and regular ; if the heart impulse is weak, and there are no 
other symptoms except such as are secondary to incomplete empty- 
ing of the heart, and if finally there is noted a paresis of other nerve- 
tracts running in the vagus, then we may assume a paralysis of the 
vagus. But when the heart impulse is strong, and the peripheral 
arteries are well filled and firm, or when there are present other 
symptoms of irritation on the part of vaso-motor nerve- tracts, then 
there is evidently an excitation of the excito-motor cardiac nerves. 

Fraentzel suggests that in addition to the above rules the effect 
of our therapeutic measures will also aid in diagnosis. If morphine 
quiets the attack it must be due to a condition of excitement ; but if 



698 THE PRACTICE OF MEDICINE. 

there is paresis of the vagus, then digitalis in moderate doses will 
allay the paroxysm. In many cases, however, both morphine and 
digitalis are without effect. 

Prognosis. — The prognosis of the disease is very doubtful, espe- 
cially at the beginning of a paroxysm. The unfavorable factors are 
a tendency to syncope, extensive pulmonary congestion, great pre- 
cordial pain, and the unstable condition of the heart at the end of a 
long attack. Of the twenty-seven cases under consideration, eight 
died, two or three were apparently cured, and the others remained 
always liable to attacks, with possible termination in collapse, syncope, 
or fatal pulmonary congestion. Dr. Wood, however, takes a more 
hopeful view of the affection. He believes that it has no tendency 
to shorten life or to develop organic disease. His patient was still 
living at the age of eighty-seven, though he had been subject to the 
attacks from his thirty-seventh year. But the disease was evidently 
of a very mild form in his case, as the paroxysms were of short du- 
ration, never exceeding twenty-six hours. We have already seen 
that the dangerous secondary complications do not develop in such 
short attacks." 

Treatment. — In the treatment of essential paroxysmal tachycar- 
dia we have to consider, (1) the management of the paroxysm itself ; 
and (2) that of the intervening periods in order to prevent their 
recurrence. During the paroxysm the patient should rest in bed or 
on a lounge — sometimes in a reclining chair, as fainting often occurs. 
All movement and exciting emotions should be avoided. Because 
the paroxysms cause nervous patients to be frightened, they should 
be assured in a decided manner that no danger need be feared if 
they keep quiet during and for some hours after a paroxysm. It is 
best not to examine the heart by percussion or with a stethoscope, as 
it causes the patient anxiety, and often excites or aggravates a par- 
oxysm. The ear can be applied to the chest and will give us all the 
information we need. The remedy selected should be indicated not 
only by the subjective symptoms but by the pathology. If the heart 
is structurally sound, and the cause is purely neurotic, we shall find 
in aconite, asafcetida, belladonna, aurum, amyl, coffea, castoreum, 
cannabis indica, cactus, camphor, coca, crocus, glonoine, ignatia, 
kalmia, lachesis, moschus, nux vomica, pulsatilla, sepia, spigelia, 
spongia, Scutellaria, tarantula, sumbul, valerian, veratrum album, 



DISEASES OF THE HEART. 699 

and veratrum viride, appropriate remedies. Dr. Snader, in his Rep- 
ertory (Hale's " Diseases of the Heart "), gives the concomitants, 
etc. The mental symptoms connected with the paroxysms are very 
important. Such is the power of u suggestion " upon the nervous 
system that we cannot always know how much the medicine has to 
do with the arrest of the paroxysms. The belief of the patient 
that you are giving something to relieve will often aid in arresting 
them. This is especially the case in hysterical tachycardia. Cho- 
reic tachycardia has paroxysms which are very difficult to control. 
While spigelia, cimicifuga, hyoscyamus, and arsenic will cure the 
chorea, it requires chloral hydrate or bromide of sodium to arrest 
the paroxysm. Some paroxysms are notable for the violent, forcible, 
heaving action of the heart. In such cases veratrum viride in doses 
of five drops every half-hour will often arrest it, after a few doses. 
Veratrum album in smaller doses is often equally efficient. One of 
the most interesting and violent cases ever treated by me was in a 
man addicted to whisky, tobacco, and excessive venery. I tried 
many medicines without avail during the paroxysms, and always had 
to resort in the end to opium. Twenty drops of laudanum always 
arrested them in fifteen minutes. None of the heart tonics of the 
digitalis group should be used unless there is dilatation or weakness 
of the heart. They are powerless, or aggravate in purely neurotic 
paroxysms. They do not cause palpitation in a normal heart, in which 
they are neither homeopathic or antagonistic. In the literature of 
this subject some singular remedies are recorded. One patient was 
able to delay the paroxysms by taking a deep inspiration and then 
suspending breathing as long as possible. (This I have several times 
verified.) Nothagel thinks that a deep inspiration exerts a strong 
stimulus on the pulmonary fibres of the pneumogastric. This stim- 
ulus transmitted to the medulla excites the activity of the inhibitory 
cardiac centres. Dr. Wood reports a patient who could arrest the 
paroxysm by swallowing cold water or hot coffee. These probably 
act on the cardiac centres through the nerves of the stomach. Com- 
pression of the vagus in the neck, at the level of the thyroid car- 
tilage, was successful in slowing the heart in several cases. In one 
of these cases the carotids were compressed and the patient fainted. 
Afterward the carotids were avoided, the pressure being applied 
behind them, and the attacks were arrested. Brieger tried this 



700 THE PRACTICE OF MEDICINE. 

method and was able to reduce the pulse from two hundred and fifty 
beats to eighty in the minute. This effect, however, only lasted dur- 
ing the continuance of the pressure. Pressure on the right ovarian re- 
gion also slowed the pulse, causing at the same time marked cyanosis. 

In patients who have during the paroxysms, cyanosis with a cold, 
clammy skin, forcible dilatation of the sphincter ani will quickly 
restore the capillary circulation and relieve the heart. 

The radical treatment should be directed to the nervous system ; 
the object being to regulate the irregular action of the nerve-centres 
which control the heart. The use of opium, morphine, alcohol, 
tobacco, coffee, and tea should be prohibited or closely restricted. 
All intense business or emotional excitement must be avoided. With- 
out giving special indications for all the medicines useful, I will sug- 
gest that ignatia, aurum, nux vomica, strychnine, and ferrum are the 
most useful. Their use should be continued for weeks or months if 
we expect to make permanent cures. 

Since the above was written a typical case came under my care. 
A woman aged fifty has had paroxysms since girlhood, commencing 
with violent and rapid beating of the heart; pulse quick — 150 to 
170 — and hard. As the paroxysm progressed the force of the 
heart's action decreased, until the pulse became very weak, and dif- 
ficult to count by reason of its rapidity. When called to attend her 
in her last paroxysm, which had lasted forty-eight hours, she had 
taken cactus, ignatia, and convallamarin, without arresting it. The 
pulse was extremely rapid and weak. Glonoine, one drop of the one 
per cent solution every two hours, alternated with four drops of the 
tincture of digitalis every two hours, was given ; after six hours the 
pulse was fuller and stronger, 120 per minute. The medicine was 
suspended twelve hours, when, the pulse being the same, the medi- 
cine was given two hours apart, when it soon became normal. In a 
subsequent paroxysm in the same patient, when the action of the 
heart had become very quick, feeble, and rapid, other remedies having 
failed, spartiene sulphate lx, one grain every half-hour, restored the 
normal action of the heart in three hours. This drug when properly 
selected acts quickly and favorably. It seems to act specifically upon 
the retardator nerves which govern the action of the heart. It does 
not regulate the rhythm like digitalis, but slows the heart and restores 
its normal frequency. 



DISEASES OF THE HEART. 701 

" Dr. Poulet, of Plancher-les-Mines, has recently found a remedy 
for paroxysmal tachycardia in a little-known plant indigenous to 
Alsace, which appears to exert a rapid and beneficial influence over 
the paroxysms. The plant in question is the coronilla varia, ovfau- 
cille, which, like some other species of coronilla, is sometimes used 
as a household remedy, being considered to have cathartic and diu- 
retic properties. Some recent researches by MM. Spillmann and 
Haushalter on a closely allied species, coronilla scorpioides, showed 
that that plant acts as a powerful heart tonic, causing an increase 
in the arterial tension and in the fullness of the pulse, exciting 
diuresis and diminishing oedema and dyspnoea, acting, in fact, very 
similar to digitalis. Dr. Poulet was induced by these researches to 
make trial of coronilla varia in heart cases. He employs a tincture 
made from the entire plant, also a powder made from the flower. 
The dose per diem of the tincture is from half a drachm to a drachm, 
and that of the powder from fifteen to thirty grains. These prepa- 
rations, though they have a strong characteristic odor, are not nearly 
so disagreeable to the taste as those of coronilla scorpioides. Details 
are given of two very severe cases in which these preparations of the 
coronilla varia gave almost immediate relief. M. Poulet recom- 
mends this drug also in other heart cases where digitalis has been 
used, and where it seems to have been given for too long a period, 
or, as sometimes occurs, where it has begun to act on the gastro- 
intestinal canal." 



PEKSISTENT TACHYCARDIA. 

Under this new name I propose to give the etiology and treatment 
of that mysterious disease known as " Basedow's disease," " Graves's 
disease," and " Exophthalmic Goitre." This disease has not yet had 
a specific name, or one suited to its real character and cause. Nor is 
Tachycardia a name that fills all the requirements, for it means 
only a " rapidly beating heart," but it is a better name than any 
heretofore given. 

This disease, in its complete form of the symptomatic triad, 
namely : " palpitation with throbbing of the arteries of the neck, 
vascular turgescence and enlargement of the thyroid body, and prom- 
inence of the eyeballs," was first described by Graves in 1835. But 



702 THE PRACTICE OF MEDICINE. 

this triad is not always complete, as has been witnessed by many 
observers. I have seen many cases, which were true examples of 
this malady, where the protrusion of the eyeballs was not present, 
while the enlargement of the thyroid was, and other cases where 
neither the thyroid nor the eyeballs were affected. 

The fact is, that this disease is not a disease of the heart, but of 
the vaso-motor centres in the brain, or of the ganglia in the sympa- 
thetic. Graves supposed it was a " cardiac neurosis," i. e., having 
its seat in the cardiac ganglia. Niemeyer attributes this affection 
to a " palsy of the vaso-motor nerves." Trousseau thinks it a " neu- 
rosis of the sympathetic from congestion or structural change of the 
ganglionic system." Brunton is of the opinion that the disease is due 
to " direct stimulation of the accelerator nerves of the heart which 
descend from the vaso-motor centre in the medulla oblongata in com- 
pany with the vertebral artery, and after passing through the infe- 
rior cervical ganglion of the sympathetic are supplied to the heart." 
He explains that the protrusion of the eyeballs, the enlargement of 
the thyroid, and the vascularity and degeneration of the sympathetic 
ganglia are from the same cause. Hayden believes that this " singular 
combination of symptoms depends on vaso-motor paresis." My 
observations have convinced me that Hayden 's opinion, added to that 
of Brunton, is correct. But I believe that in many cases alternate 
and opposite states of the vaso-motor nerves occur, — at one time 
paresis, and at other times irritation. 

" The questions of the pathology and the morbid anatomy of this 
disease," says Dr. Hammond, " have always been enigmas, and have 
not to this day been positively and satisfactorily settled, though prob- 
ably the solution of the problems is not far distant." A year or two 
ago it was almost universally believed that certain lesions discovered 
in the cervical sympathetic were responsible for the symptoms. At 
this date there are many and potent reasons for believing that, in the 
majority of cases at least, the sympathetic system is not involved at 
all, or, if it is, it is involved secondarily, and that the lesion is of 
an irritative nature and is situated in the medulla oblongata. It may 
possibly not be long before the origin of the disease can be traced to 
even a higher level, — that is, to the cortex, — for it is well known 
that mental shocks, such as fear, which unquestionably affect the 
cortex, have resulted in exophthalmic goitre, just as they have in 



DISEASES OF THE HEART. 703 

epilepsy, in chorea, and many other forms of nervous diseases. At 
the present time, however, it is only necessary to consider the two 
theories which can be supported by any evidence which is in the least 
degree conclusive. These theories are : (1) That exophthalmic goitre 
is due to disease of the cervical sympathetic system. (2) That it 
is due to an abnormal condition of the medulla oblongata. 

In regard to the first theory, the evidence goes to show that in 
many cases post-mortem examination discloses diseases of the sympa- 
thetic nerve, and particularly of the cervical ganglia. The changes 
observed in the ganglia are enlargement, hardness and redness, gran- 
ular degeneration, infiltration with round cells or with spindle-shaped 
cells, destruction of the ganglionic structure with increase in the 
amount of connective tissue. Physiological experiments on the sym- 
pathetic nerve also prove conclusively that the symptoms of exoph- 
thalmic goitre can be produced artificially by this means. 

The arguments against this theory are certainly very convincing. 
A number of cases are recorded where no change can be discovered 
in either the sympathetic nerve or its ganglia. Hammer, in a report 
of a case of his own, where no lesion of the sympathetic could be 
discovered, cites twenty-two other cases where autopsies were obtained. 
Of these, seven showed lesions in the sympathetic system, while in 
the fifteen remaining no sympathetic lesion could be discovered at 
all. Two other autopsies have been reported since then, in neither 
of which were the sympathetic nerves diseased. As to the physio- 
logical experiments, though it is admitted that many of the indi- 
vidual symptoms, such as dilatation of blood-vessels, exophthalmia, 
enlargement of the thyroid gland, contraction of the lids, and accel- 
erated action of the heart, can readily be obtained by producing arti- 
ficial lesions of the sympathetic, it is well known that any one such 
lesion cannot result in all of these symptoms, since some of them are 
produced by paralysis and others by irritation of the sympathetic. I 
think it will be admitted that it is clearly impossible for any one 
lesion to produce both irritation and paralysis at the same time. The 
theory of a central lesion is far more acceptable to my mind. In the 
first place, centres are known to exist grouped together within a small 
area in the medulla, lesions of which result in the appearance of the 
three principal symptoms of the disease. 

Filehne, in his experiments, produced each of the three symp- 



704 THE PRACTICE OF MEDICINE. 

toms in turn, and, in one case, all three of them together, a result 
which has never been attained by any single lesion made on the sym- 
pathetic. Probably the fourth symptom — Dr. Bryson's symptom — 
was obtained also by Filehne, although, not knowing of its existence, 
he probably did not look for it. In the second place, it does not 
seem unreasonable to attribute the three principal conditions of vagus 
paralysis, vaso-motor paralysis, and respiratory paralysis, which pro- 
duce the four principal symptoms, accelerated heart action, enlarge- 
ment of the thyroid gland, exophthalmia and diminished chest expan- 
sion, to a single circumscribed lesion affecting the vagus nucleus, 
the vaso-motor nucleus, and the respiratory nucleus. Polyuria, which 
is a frequent symptom of Graves's disease, can also be produced by 
a lesion in this region. Physiological research is not unsupported 
by post-mortem evidence. Dr. W. Hale White, " British Medical 
Journal," March 30, 1889, has reported a case where "the sympa- 
thetic was found to be healthy. A series of sections were made from 
the lowest part of the medulla to the corpora quadrigemina. At the 
level of the lowest part of the olivary nucleus there was, just under 
the posterior surface of the medulla, evidence of slight inflammation. 
The next few sections were quite healthy, but those in the neighbor- 
hood of the sixth nerve showed considerable changes. Immediately 
under the posterior surface of the medulla, extending from the 
mesial line as far out as the restiform bodies, which were slightly 
implicated, were numerous hemorrhages. The area occupied by 
these hemorrhages did not extend deeply, so that, except for a slight 
implication of the nerve cells of the sixth nucleus on one side, the 
nerve cells had escaped injury. The hemorrhages seemed almost 
entirely limited to the posterior part of the formatio reticularis, but 
there were two or three small deep ones. They were not marked at 
this level, but were observed up to the lower part of the aqueduct of 
Sylvius." Dr. White believes this is the first case where organic 
lesions have been discovered in the medulla in exophthalmic goitre, 
but Lockhart Clark reports a case where the " corpora quadrigemina 
and the medulla, particularly on its posterior part, were very soft, 
and, on minute examination, displayed the usual appearance of com- 
mon softening." 

There is a strong probability that there is a general dilatation of 
the blood-vessels. It has been conclusively shown that in exophthal- 



DISEASES OF THE HEART. 705 

mic goitre the electrical resistance of the patient is very much dimin- 
ished below the normal point. And although, as yet, there is no 
absolute proof, it seems plausible and probable that a generally 
dilated condition of the vessels would account for the greatly dimin- 
ished electrical resistance. In many instances no lesion has been 
discovered at all, and the burden of proof goes to show that exoph- 
thalmic goitre is frequently a reflex neurosis. It is not essential that 
even the fatal cases should be of organic origin, as a reflex irritation 
can readily be imagined to be of so powerful a nature as to produce 
almost total degeneration of the nerve cells in the medulla, which, of 
course, in the present state of our knowledge, would be undetected 
after death. The theory that exophthalmic goitre is often of reflex 
origin is supported by clinical evidence. Simon reports a case on 
which he operated by means of the galvano-caustic loop for the 
removal of multiple recurrent mucous polypi of the nose. Within a 
day or two after the operation, exophthalmia of the right eye sud- 
denly appeared. Grsefe's and Stellwag's symptoms were both present, 
but there was no enlargement of the thyroid gland and no increased 
action of the heart. Hoffmann, of Cologne, reports a case of exoph- 
thalmic goitre which was entirely cured by an operation performed 
within the nasal cavity ; and Hack, of Freiberg, and B. Frankel, of 
Berlin, both report cases where operations for nasal diseases have 
cured cases of Graves's disease. It will not be amiss to mention here 
that Mr. George Storker, of London, reports two cases where ordi- 
nary goitre disappeared after intra-nasal operations. It will be 
observed that in all of these cases the reflex disturbance was situated 
within the nasal cavity. The thought will at once occur to us all 
that if nasal irritation can reflexly result in exophthalmic goitre, irri- 
tation in other parts of the body can do the same. It would be well, 
therefore, in the future examination of patients, to search for and 
relieve such abnormal conditions as we know are most likely to result 
in reflex neuroses. These abnormal conditions are most likely to be 
found in the eyes, the nasal cavity, and the genito-urinary appa- 
ratus." (Reflex irritations from the rectum have been known to 
cause it.) 

The deduction from the above is this, — that to cause dllfour of 
the essential symptoms of this disease united in the same subject, it 
may be necessary that the lesion shall be in the cortex, — that in 

45 



706 THE PRACTICE OF MEDICINE. 

those cases in which we find only one (tachycardia) or two (tachy- 
cardia and swelling of the thyroid), or any other combination not 
including all four, the lesion or lesions may be confined to the sym- 
pathetic, or one centre in the medulla. 

Dr. Hammond, in the New York " Medical Journal," January 
25, 1890, mentions a new diagnostic symptom. He says : " The 
usual three cardinal symptoms, upon the existence of one or more of 
which the diagnosis depends, are so well known as to need no com- 
ment. The various other symptoms, which are as often absent as 
they are present, are so familiar to you all that any further mention 
of them is superfluous ; but there is one symptom which has recently 
been discovered which deserves considerable attention. I refer to 
Dr. Louise Bryson's symptom. It has never been observed before 
as far as I can ascertain, and is of the greatest importance in regard 
to the prognosis of the disease, and is also of assistance in locating 
the seat of lesion. Dr. Bryson's symptom consists in the inability 
of the patient to expand the chest under forced inspiration up to the 
normal extent. In every case that has been examined since Dr. 
Bryson's discovery, this deficiency has been observed. In some 
instances the loss of the power of expansion is remarkable, and Dr. 
Bryson states that where the expansion is found to be reduced to 
half an inch or less, the termination of the case is invariably fatal. 

" This statement has been sustained in at least one case that I 
know of. In five cases that came under the care of my assistant, 
Dr. Combes, and in three cases that came under my personal inspec- 
tion, this symptom was observed ; and in all of the cases, as recovery 
gradually took place, the power of the chest expansion has been 
slowly restored." 

I have a patient who has suffered from this disease for three 
years (the protrusion of the eyeball is not present), whose chest 
expansion is only three-quarters of an inch. 

Dr. E. C. Williams reports a typical case of a year's duration 
whose chest expansion was only one-half inch, but under spigelia it 
has increased to one and a quarter inches. 

This symptom should be observed hereafter in every case, and 
its improvement under remedies noted carefully by measurement. 

A new pathognomonic sign of exophthalmic goitre has been 
described by Dr. P. Guttmann, before the Berlin Medical Society : 



DISEASES OF THE HEART. 707 

" The patients before you are thirty-four and thirty-eight years of 
age respectively. These women are both suffering from Graves's 
disease. In both of them by placing the stethoscope over the thyroid 
one hears a characteristic blowing murmur synchronous with the 
heart-beats. This murmur is never heard in cases of goitre which 
are not directly associated with Graves's disease. It is produced in 
the thyroid itself independently of the existence of any cardiac lesion. 
It is due, in the first place, to hypertrophy of the left ventricle, a fre- 
quent complication of Graves's disease, and in the second place, to 
unequal distribution of the blood throughout the thyroid vessels. 
The vessels being irregularly dilated, the blood in its passage through 
them is thrown into vibrations which give rise to the blowing sound. 
I repeat, nothing of the kind is ever observed in cases of goitre due 
to other causes than Graves's disease. The presence of a murmur 
over an enlarged thyroid is, therefore, of the greatest importance in 
the diagnosis of Graves's disease, especially in cases where one of the 
three cardinal symptoms of the affection is wanting. In 1867, Von 
Grsef e observed that cases of exophthalmic goitre are associated with 
a deficient upper eyelid. This sign is not so constantly present as 
one I have just indicated. As regards the blowing sounds heard 
over the jugular veins, they are of no value whatever for purposes of 
diagnosis." 

The causes are mental emotion of any sudden intense nature ; 
mental worry long continued ; a fright or mental shock ; prolonged 
watching and anxiety. In fact, most authorities agree that nearly 
all cases originate from the mental sphere. In a few cases the cause 
was supposed to be violent physical exertion. I can recall but few 
cases out of the many I have seen that had other than mental or 
emotional causes, so far as I was able to trace their history. The 
pulsations of the heart and the radial and other arteries are generally 
rapid, full, and strong, reaching sometimes as high as 160 per minute. 
But I have seen this condition change in a day to a condition in 
which the pulsations of the heart and arteries were irregular, inter- 
mittent, and feeble, and continue so for weeks or months ; then sud- 
denly reverting to the former condition. All this points to an alter- 
nating vaso-motor neurosis. The mental states of the patients are 
peculiarly changed. A person previously of mild and amiable tem- 
perament will become irritable, peevish, impatient, and exacting, and 



708 THE PRACTICE OF MEDICINE. 

alternately excited and depressed, or joyous and melancholy by turns. 
In many cases a hysterical condition is clearly present. The temper- 
ature is generally elevated, but I have known cases in which it was 
subnormal. Morbid appetite and anorexia alternate. The menses 
are sometimes profuse ; at other times scanty. There may be diar- 
rhoea or constipation, both very obstinate. 

The treatment of this disease has had a most varied history accord- 
ing to the diverse and various theories as to its cause. Those who 
believed that anaemia was the cause, relied on the use of iron ; others 
gave digitalis, believing it was a local cardiac neurosis. Iodide of 
potassium had its friends. Electricity and galvanism were used to 
combat the supposed paralysis of the sympathetic. Iodine has been 
used for the goitre, but never with decidedly good effects. Belladonna 
has been given with good results by the dominant school for its sup- 
posed antipathic action, while it was really homeopathic. But only 
a few real cures have been made with these agents. Our own school 
has not been much more successful because the supposed homeopa- 
thicity of the remedies selected was only apparent, not real. There 
are, according to my studies and observations, only three real homeo- 
pathic remedies for this strange disorder. They are aurum, glon- 
oine, and spigelia. Belladonna may be added to the list, but it does 
not cover all the symptoms. Belladonna has long had some reputa- 
tion in this disease. The rapid heart, the arterial turgescence, and 
many concomitant symptoms point it out as a remedy according to 
the law of similia, but it causes neither protrusion of the eyeballs or 
enlargement of the thyroid, although it increases the size of their 
arterial vessels. I admit that it ought to be an excellent palliative, 
but I doubt its ability to cure. Yet some cures are claimed by both 
schools in doses ranging from the 3x dilution down to one-fourth 
of a grain of the extract several times a day. I have not made any 
cures with small or large doses. 

Aurum has the arterial and cardiac excitement, but lacks some 
of the local symptoms. 

The bromide of gold has been used in typical cases of Basedow's 
disease by some French physicians with alleged success. In two 
cases I saw marked improvement from the 2x trituration in two- 
grain doses Cone-fiftieth of a grain) three times a day. It relieved 



DISEASES OF THE HEART. 709 

the cerebral throbbing, the mental irritability, melancholia, and the 
cardiac excitement. 

Glonoine has the vaso-motor paralysis to a great degree. It has 
the sensation and even, to some extent, the real protrusion of the 
eye-balls. No remedy yet found has the swelling of the thyroid in 
connection with the tachycardia. In fact, no known drug ever caused 
a swelling of the thyroid or anything like a goitre. 

Glonoine has done good work for me when the throbbing and 
congestion of the head resulted in positive pain. Here the third 
dilution was used. It has also been of great value in those cases 
where sudden cardiac syncope threatened ; the heart's action becomes 
very feeble and irregular, pulse scarcely felt, and the patients thought 
they were dying. But the proper dose in such cases is the one- 
fiftieth or one-hundredth grain (one or two drops of the lc). 

The experiments on animals with spigelia, recorded in the last 
edition of my " Diseases of the Heart," present a perfect and graphic 
picture of Basedow's disease, including the violent action of the heart, 
its great rapidity of action, the great protrusion of the eye-balls, and 
many other symptoms. The provings also show in a marked degree 
its close homeopathicity. Yet it has been but little used in this dis- 
ease, and then only as a palliative. Since those experiments were 
made and published, I have not had a typical case calling for spi- 
gelia ; therefore I cannot give any personal experience with it. I 
would advise that it be used with caution as to dose, giving not 
lower than the 3x. 

A case illustrating the curative action of Spigelia, reported 
by E. C. Williams, M.D., of Chicago. — " Miss A. came to me for 
treatment with the following history : In June, 1889, she com- 
menced to be troubled with palpitation of the heart (for some months 
previous to this had not been in good health, she, being a nurse, 
having to work very hard, with irregular hours). With the palpi- 
tation had come some acceleration of the pulse, but with no appar- 
ent abnormal heart symptoms. About two months later struma was 
developed, the enlargement in the course of a short time increasing 
the circumference of the neck about two and one-half inches. This, 
however, was subject to changes, varying in size. Almost imme- 
diately following this, exophthalmia developed, the left eye more 



710 THE PRACTICE OF MEDICINE. 

prominent than the right. At the time of her coming to me she was 
greatly emaciated, suffering intensely with stabbing pains in and 
about the heart. There was an insufficiency of the mitral and aortic 
valves. The chest expansion was only three-quarters of an inch. 
The pulse was from 140 to 160 beats per minute ; temperature about 
normal ; sleep was disturbed ; respiration was hurried, and at times 
caused great aggravation of the 4 stabbing ' pains. There was great 
loss of muscular power ; in fact, an almost total inability to help 
herself in any way. Several remedies were tried in rapid succession 
with no benefit whatever. At last she was put upon spigelia 2x, 1 
being led in that direction by the chapter on spigelia in Dr. E. M. 
Hale's new edition of his work on the ' Heart.' This drug was pre- 
scribed for two weeks, when I thought there was some general 
improvement. The pains about the heart were certainly relieved. 
She was then put upon spigelia 6x. In three weeks more there was 
a marked diminution in the swelling of the thyroid, the protrusion 
of the eyeballs was less marked, and the pulse-rate was down to 
125. This remedy has been prescribed in from three to five times 
in twenty-four hours, and at the present time the pulse-rate is 80 ; 
temperature normal ; the swelling at the thyroid has entirely disap- 
peared ; the exophthalmus is no longer present ; the expansion of 
the chest is one and three-quarters inches, and the abnormal condi- 
tions of the heart are much improved. The lady has gained twenty- 
five pounds in weight. I am confident now that she will entirely 
recover." 

If we feel we ought to use some preparation containing iodine, 
spongia is the best, for in its provings we find many symptoms which 
make it applicable to this disease. Of the newer remedies, I can 
give some personal experience. 

Lycopus will often give great relief, but it is only indicated when, 
with some exophthalmus, the pulmonary symptoms are the most 
prominent. Cough, haemoptysis, and hectic fever, together with the 
rapid pulse of 140 or more, call especially for this drug. I do not 
usually give smaller doses than the lx, and have often seen the 
best results from five-drop doses of the tincture, frequently repeated. 

Baryta muriatica (chloride of barium) is a drug which ought to 
be beneficial in some cases of Graves's disease. Kecent experiments 
show that small doses are capable of slowing the heart, and making 



DISEASES OF THE HEART. 711 

its action fuller and stronger. Now we know that baryta has great 
influence over indurations and enlargements of glandular structures, 
and also to check abnormal development of connective tissue. It 
seems to me that it ought to be of service in this disease when occur- 
ring in the old or prematurely aged, when with a tendency to fatty de- 
generation and atheroma, there occurs tachycardia with weak heart, 
and enlargement and induration of the thyroid. It also has the 
power of contracting the muscular tissues of arteries and veins, and 
must therefore act on the vaso-motor centres. 

Convallaria differs from other cardiac sedatives in its greater 
power of quieting and calming the nervous system. In Graves's dis- 
ease, as I have above stated, the mind and brain becomes very irri- 
table, and the emotional sphere morbidly sensitive. Here, the lily of 
the valley has a very happy effect, calming the almost hysterical 
erethism as well as the tachycardia. The unpleasant general throb- 
bing of all the arteries is lessened under its influence. The dose is 
five to ten of the mother tincture or lx three or four times a day. 
Always use the tincture of the flowers. 

The following case reported by Dr. W. A. Smith, of Morgan 
Park, 111., illustrates the action of convallaria : 

" Mr. , aet. 42, light complexion, presented himself for treat- 
ment in April, 1883, with the following symptoms : Rapid action of 
the heart, averaging 114 beats per minute the first month ; eyes 
slightly protruding, and some enlargement of the thyroid gland. 
He complained of feeling tired, that he could stand no work or any 
excitement on account of his heart. Appetite capricious ; could not 
sleep very well ; had frontal headache, worse in afternoon. The 
stethoscope gave a rather peculiar sound that was anaemic in char- 
acter. As he was a stranger to me, I did not take any particular 
notice of the eyes or gland, and the diagnosis of the disease was not 
given, but prescribed bell. 3 Ox, four pellets every three hours. The 
only improvement was that he rested better, and did not complain 
of his head. Then I gave iod., dig., ars. iod., and, after them, every 
remedy in whose symptomatology the word gland was used. After 
he had been under treatment about six months, and slowly losing 
ground, he became dissatisfied, and decided to go to Ohio and try 
his old family physician, and I bade him God-speed, glad to get him 
out of my care. He was away more than three months, when he 



712 THE PRACTICE OF MEDICINE. 

returned with marked aggravation of all the symptoms. Pulse 130, 
eye-balls very prominent, and the right side of the gland nearly 
double the size it was when he left. He requested me to again assume 
charge of the case, and not feeling competent to handle it any more 
satisfactorily than before, I went to Chicago and consulted with Dr. 
E. M. Hale. He suggested the use of convallaria tincture, Rye 
drops every four hours, for the heart, and under its use the action 
of that organ became nearer normal, and decreased to 100 beats per 
minute ; but, do what I could or would, he was getting weaker, and 
when I would stop the convallaria the pulse would bound to 130 or 
more per minute. He had become almost a skeleton. The conclu- 
sion was, that he must be better nourished, and the heart's action be 
reduced ; so I increased the convallaria to ten drops every five hours, 
and gave beef peptonoids. I never saw anyone do better than he 
under this treatment ; and inside of four months he was at work, 
and has been ever since. 

" The patient died in 1889, of some liver trouble, but not being 
in attendance I cannot say if the old exophthalmic difficulty returned 
or not." 

Collinsonia has rendered me good service in a few cases when 
hemorrhoids complicated the case to an unpleasant degree. Hayden 
mentions a particularly bad case of Graves's disease brought on by 
painful bleeding piles. 

Oleander, as you will see by the provings and recent pathological 
experiments, is a heart poison which accelerates and depresses the 
motor function of the heart. Its alkaloid, nerine, or oleandrine, is 
as powerful as digitalin. I have never used it, but would suggest it 
in those cases attended with diarrhoea of undigested food, a condition 
sometimes observed in this disease. 

Aconite has been used by both schools in Graves's disease, but I 
have never seen good results from it except when the pulse is small, 
tense, and rapid, symptoms which are rare, but have sometimes been 
observed. Generally, vaso-motor paresis is present, but vaso-motor 
irritation, with great vascular tension, has been observed. 

Dr. E. C. Sequin, New York " Medical Journal," April 26, 1890, 
speaks highly of aconitine in some cases. In a recent lecture on this 
disease he says : 

" The two new measures I wish to call your attention to are, first, 



DISEASES OF THE HEART. 713 

the systematic employment of aconitine, and, second, bandaging of 
the protruding eyeballs. In 1884 I rather accidentally discovered 
that aconitine (the crystallized aconitine of Duquesnel) exerted a 
powerful reducing influence on nervous or irritative fast pulse, i. e., 
a fast pulse with high tension and normal heart, easily distinguished 
from the fast pulse of cardiac disease or general debility or fever. 

" (Of course, it has long been known that aconite reduces the 
pulse. I refer to a very decided effect upon a special sort of a 
pulse.) 

" Aconitine in granules of l-200th of a grain greatly reduces the 
pulse-rate and also the arterial tension. In Basedow's disease I give 
from three to eight pills a day for days and weeks, occasionally stop- 
ping for a few days. On the average, it is necessary to give two pills 
three times a day ; under this the pulse-rate steadily falls from the 
upper limits of 160 or 140 a minute to below 100. After that the 
fall is slower, but in many cases goes on until ninety, eighty, and 
even seventy beats are recorded to the minute. At the same time 
the eyes and neck usually improve. This treatment occasionally 
fails, but it never does any harm. I have used it in quite a number 
of cases, some without goitre and exophthalmia, since 1884, and it 
has been tried with good results by several of my professional friends. 
At the same time iodide of potassium or iron may be given and gal- 
vanism applied in the usual way." 

Strophanthus is certainly more efficacious in this disease than dig- 
italis. Why this is so I cannot explain, because we have no exten- 
sive provings of it. I imagine, however, that its action is more upon 
the accelerator nerves and less upon the intercardiac ganglia. It has 
more influence on the thyroid than digitalis, and its sedative action 
is more lasting. Once the pulse becomes slower, it does not regain its 
quickness for many days after its use is suspended. In one case it 
cured the uterine hemorrhages, which were rapidly reducing the 
patient. The dose varies from five to ten drops of the Ix to the 
same quantity of the tincture three or four times a day. 

Dr. Hammond (Joe. cit.), of New York, says : "Experiments by 
Fraser, Drasche, Zerner, and Loaw show that strophanthus prolongs 
the diastole of the heart, causes it to beat more slowly, and to dis- 
charge at each contraction a larger quantity of blood into the arte- 
rial system ; at the same time the arteries become contracted. These 



714 THE PRACTICE OF MEDICINE. 

facts are clearly expressed in an article in the ' British Medical 
Journal.' 

" Bakadhurji, who experimented with strophanthus in coopera- 
tion with Langgaard, of Berlin, found that strophanthus has a 
marked effect upon the vagus. They report also that the respirations 
are at first increased, but are subsequently slower and weakened. 
This may be the result on the healthy organism, but in exophthalmic 
goitre, at least in the cases that have come under my observation, the 
respiration becomes slower and stronger, while the power of expan- 
sion becomes greater. It is, therefore, probable that strophanthus 
affects the central respiratory centre as well as the vagus centre. If 
these statements are true, we have in strophanthus a remedy which 
would exert a powerful influence in subjugating the four principal 
symptoms of exophthalmic goitre, namely, the exophthalmia, the 
enlargement of the thyroid, the cardiac rapidity, the shortened respi- 
rations, and the diminished chest expansion. Zerner and Loaw have 
employed strophanthus with success in this disease. Brower reports 
three very interesting cases which were cured by this drug in from 
four to six weeks. Three cases of my own showed decided improve- 
ment under its use. Other observers have used it with advantage, 
but the foregoing cases are sufficient to show its practical utility in 
many instances. The only preparations of the drug which can be 
obtained are the tincture of strophanthus and strophanthine. The 
latter is hardly available for therapeutic purposes, as its extreme 
potency renders its use dangerous. The ordinary dose of strophan- 
thine is l-5000th of a grain." 

Dr. Hammond, in the same article, says : " The other remedy 
which I wish to call your attention to is the carbazotate of ammo- 
nium. As a remedy for exophthalmic goitre, we are indebted for 
its discovery to my clinical assistant, Dr. A. C. Combes. He dis- 
covered it accidentally in the following way : A patient afflicted with 
exophthalmic goitre consulted him nearly a year ago. She had been 
under the care of a well-known New York physician, who, not recog- 
nizing the nature of her complaint, and thinking she was suffering 
from some febrile disease, gave her the carbazotate of ammonium. 
She was subsequently told the name of her disease, and, feeling dis- 
satisfied with her physician, she left him and consulted Dr. Combes. 
Dr. Combes found that under the drug she was taking, her symp- 



DISEASES OF THE HEART. 715 

toms were disappearing. He continued the remedy with excellent 
results, and has since used it on five cases, and in all of them with 
benefit. I have used it on three cases of my own with, I think, 
decidedly good results. Its use is, however, limited, and for reasons 
which I will now mention cannot be given indefinitely. Following 
the direction of Dr. Combes, I have given the remedy in pill form 
(each pill containing one grain of the drug) three times a day for 
the first week. In the second week, two pills three times a day are 
given, and, if it can be borne, three pills three times a day in the 
third week. The physiological effects of the drug are very decided. 
They were observed by Dr. Combes, and his observations have been 
verified by my own. At about the end of the first week the skin 
and conjunctivae assume a slight saffron color, which deepens if the 
drug is persisted in. Then a peculiarly unpleasant odor emanates 
from the body, which is identical with that produced by dirty feet, 
and can be distinctly noticed if you approach within six or eight 
feet of the patient. Following this, severe gastric disturbances show 
themselves. 

" It is rarely possible ^iat patients can take this remedy longer 
than three weeks, but while they take it the effects upon the heart, 
the respiratory tract, and the exophthalmia are undoubted." 

This drug, called by Dr. Hammond " carbazotate of ammonium," 
is known to us under the name of " picrate of ammonia," in which 
picric acid is the real efficient agent. An examination of the prov- 
ings and physiological experiments given in Allen's " Encyc. Mat. 
Med.," shows that it causes many of the prominent symptoms of 
Basedow's disease, viz., the headache with throbbing in the cerebral 
arteries ; pain and soreness in the eyeballs ; great irritability of tem- 
per ; sensation as if a band encircled the chest ; palpitation of the 
heart, etc. But it is doubtful if the drug is really homeopathic to 
the state of the heart. In the cases where the heart was slowed, the 
doses were large (from one-fiftieth to one grain). In those cases 
the pulse fell from seventy and seventy-five to fifty-five and fifty. 
This was a physiological or pathogenetic effect. The primary effect 
of picric acid may be vaso-motor paresis, with increased action of 
the heart, similarly to aurum, spigelia, and glonoine ; but the sec- 
ondary effect may be the opposite, though we do not really know. 
I have never used picrate of ammonia or picric acid in this disease, 



716 THE PRACTICE OF MEDICINE. 

nor would I use it or advise its use in such doses as Hammond ad- 
vises. There may be cases calling for its use as a palliative (home- 
opathically), and at present we may restrict it to them. 

Veratrum viride has been used in exophthalmic goitre. The fol- 
lowing case is reported by Dr. Hutchins, of Madison, Ind.: 

" Mrs. B. applied to me for treatment July, 1879. Height, above 
medium ; weight, ninety-three pounds ; age, thirty-five ; mother of 
three children ; her condition, anaemic ; greatly debilitated ; heart 
apparently much dilated, without rhythm, with a wallowing move- 
ment ; eye globes so protuberant as almost preventing closure of lids, 
presenting shock deformity ; goitre not measured, but very promi- 
nent ; mind deranged. She had suffered with this malady, gradually 
increasing in gravity, for twelve years. Had been under the treat- 
ment of several home physicians, and finally, while visiting in Phila- 
delphia, consulted a physician of that city, who diagnosticated exoph- 
thalmic goitre, and advised her to return home immediately as she 
was liable to fall dead at any hour. I confirmed his diagnosis, and 
placed the patient on tincture veratrum viride, three drops morning 
and night, to be gradually increased until the full dose possible to 
tolerance was obtained. At first the three drops was barely toler- 
ated ; four drops produced such weakness as to oblige her to take to 
bed for a short time. She persevered, however, until twelve drops 
were taken morning and night without producing nausea or any 
inconvenience whatever. This dose was continued twice daily for 
twelve months, then dropped to one dose daily for a few following 
months. The improvement of the patient was gradual but progres- 
sive, and at the expiration of twelve months from beginning of treat- 
ment the goitre had disappeared, the eyeballs had receded to their 
normal position, the mind had returned, and her weight was ascer- 
tained to be one hundred and sixty pounds. This lady was seen by 
me only at long intervals during her treatment, but she faithfully 
obeyed orders, and took the medicine with the above results. She 
is now residing in this city in the enjoyment of good health." 

This is a case remarkable for the persistence of the physician 
and the patience of the patient. Veratrum viride slows the heart 
without causing tension of the arteries. In this respect it is unlike 
any other drug. 

Cyanuret of zinc has been used very successfully in many func- 



DISEASES OF THE HEART. 717 

tional diseases of the heart. The symptoms are violent palpitation 
with sudden aggravations, accompanied by angina-like pain and a 
sense of suffocation, with vertigo and sudden unconsciousness. The 
pulse is quick and full, and there is general throbbing, with an inter- 
nal tremulous feeling. The affinity of zinc for the brain, cortex, and 
medulla makes it applicable to some forms of tachycardia due to 
paresis of the motor and sensory centres in the medulla, and to cases 
due to cerebral exhaustion. Dose, 2x trit., two to five grains three 
times daily. 

Ferro-cyanuret of potassium is preferable to any other form of iron 
when there is slow and progressive anaemia added to the symptoms 
indicating the zinc cyanuret. Several years ago I treated a case of 
chlorosis and Graves's disease with this ferrous salt. The improve- 
ment was rapid and very satisfactory. I used the lx trituration in 
five-grain doses three times a day. 

The moral treatment should not be neglected. The patients 
should be humored in their whims ; not contradicted, but treated 
with kindness and consideration, and surrounded by the best social 
influences. All exciting scenes and emotions should be avoided. 

They should be placed in a climate which agrees with them, avoid- 
ing the extremes of heat and cold or damp localities. 

Prof. Nothnagel, of Vienna, in the course of a clinical lecture on 
Graves's disease, summarizes the treatment of his school as follows : 

" Digitalis, according to common experiences, does not act at all 
on the tachycardia. It requires some firmness not to give this drug, 
but we may with comfort abstain from doing so, for it does no good. 
The same observation applies to the other remedies that act in the 
same way as digitalis. An effective agent against the palpitation is 
cold, in the form of an ice-bag, either over the cardiac region or over 
the neck. In some cases the palpitation, restlessness, and excitement 
are made to disappear or are diminished by the application of cold 
to the neck sooner than over the cardiac region. These patients 
ought to live quietly and to avoid coffee, beer, cigars, and mental 
and bodily excitement. Little or nothing is to be expected from 
medicinal remedies. According to the most recent observations, gal- 
vanism through the medulla oblongata and cervical sympathetic is 
the best treatment , but this treatment must be regular and long- 
continued, and should be associated with a hydro-therapeutic course. 



718 THE PRACTICE OF MEDICINE. 

The patient is then systematically treated in a cold-water institution 
with tepid half-baths, irrigations, wrapping in moist linen cloths 
wrung out, and the cold spinal bag. By this means, along with the 
mental quietness, an improvement in the condition is, in many cases, 
brought about. Iron can be given if indicated. In other cases, 
when patients are much excited, bromide of sodium or potassium 
may be exhibited in doses of fifteen grains twice or thrice daily. An 
important means of treatment, but one that can only be carried out 
in the cases of well-to-do patients, is to send them to the mountain 
regions, especially to the higher altitudes. By such a sojourn many 
cases are considerably benefited." 

I have never tried such treatment, and I doubt the efficacy of 
cold applied as he recommends. 

If Nothnagel's recommendation of high altitudes prove valuable, 
some elevations of the Alleghany or Rocky mountains should be 
advised, but, judging from the effects of elevations higher than five 
thousand feet, I think they should not go above that limit. 

Treatment of the Goitre. — No local treatment is of much value. 
Applications of an ointment of the iodide or chloride of barium have, 
in a few of my cases, seemed to decrease its size. Phytolacca has 
appeared to be of some benefit ; also spongia. Hypodermatic injec- 
tions of iodine and ergotine have not resulted in permanent improve- 
ment. Its excision has proved beneficial in a few cases, but a part 
of the gland should be left. 

Treatment of the Exophthalmus. — No special treatment has been 
suggested, until of late, by Dr. E. C. Sequin, who says in a recent 
paper, loc. cit.: 

" Bandaging of the eyes has never, to my knowledge, been prac- 
ticed. In the last two years I have tried it in two cases with excel- 
lent results ; complete reduction of the exophthalmia in one case. 
A carefully moulded pad of soft cotton is placed over each eye, fill- 
ing the orbit, and a light (of not more than three turns) flannel 
bandage applied with gentle but decided pressure. At first I do this 
for only an hour twice a day ; later, for periods of two or four hours. 
In one of the cases the bandage was applied at 10 P. M., and allowed 
to remain all night. During the progress of the second case, which, 
though it has existed for at least three years, is much improved, I 
have made occasional opthalmoscopic examinations without detecting 



DISEASES OF THE HEART. 719 

any damage due to the pressure. The pressure should not be great 
as it is intended simply to counteract the dilatation of vessels in the 
orbit, which is the usual immediate cause of the exophthalmia." 

I have never tried this method of compression of the eyeballs, nor 
do I remember to have seen any previous recommendation of it, but 
I can see no harm from it if it is carefully practiced. 

" Dr. J. Leonard Corning adopts the following line of treatment. 
In order to prevent the excessive blood pressure in the thyroid, cra- 
nial cavity, and orbit, he places the patient in a warm bath for 
three-quarters of an hour every day ; and sometimes, in addition, he 
applied elastic straps round the legs so as to interfere with the cir- 
culation in the veins, but not so tight as to arrest that in the arteries. 
By these means he hopes to secure a considerable amount of deriva- 
tive action, and lessen the blood supply to the thyroid. He also 
applies styptic collodion to the skin over the thyroid, and fits it with 
a carefully adjusted elastic truss. He makes daily applications of 
galvanism to the thyroid gland, employing for this purpose an elec- 
trode of potter's clay moistened with iodine, of sufficient size to 
envelop the whole gland. The negative pole, a flat sponge, is applied 
to the nape of the neck. The applications are made twice daily, for 
a period varyiug from ten to twenty-five minutes, and are continued 
for six weeks or two months at least. When the pulse is very rapid 
he gives aconite ; when not so rapid, digitalis, spartein, or strophan- 
thus. The diet is very important, and should consist largely of milk, 
of which the patient may take from two to four quarts a day. Bread 
and butter, poultry and game may be allowed in moderation. Alco- 
hol in all its forms is contra-indicated. Bitter tonics, arsenic, and 
iron will often be serviceable. Freedom from excitement and men- 
tal strain should be ensured, but simple games, musical entertain- 
ments, and a moderate amount of reading may be prescribed. The 
patient should not of necessity be kept in bed. 

As regards the electro-therapeutical treatment of Graves's dis- 
ease, Mr. H. W. Candew divides cases of Graves's disease in four 
classes : 

(1) Cases that undergo spontaneous recovery, including cases of 
women who recover during subsequent pregnancy ; (2) cases that 
obtain relief from appropriate drug treatment ; (3) cases that obtain 
relief or cure from an appropriate electrical treatment ; (4) cases 



720 THE PRACTICE OF MEDICINE 

that derive no benefit from any treatment, and believes himself jus- 
tified in stating that the cases which derive any benefit from an appro- 
priate drug treatment would derive an equal, if not a greater, bene- 
fit from an appropriate electrical treatment. He recommends the 
use of galvanism in very weak currents (two or three milliamperes), 
applied for six minutes three times a day, the anode being placed 
on the nape of the neck, the centre of its lower border correspond- 
ing to the seventh cervical spinous process, and held firmly in that 
position during the application, while the cathode is moved up and 
down the side of the neck from the mastoid process along the course 
of the great nerves. 

Dr. Louise Fiske Bryson, in the " Post-Graduate," July, 1892, 
writes : 

" The treatment securing best results has been a combination of 
mechano-hydrotherapy and rest and exercise, together with the strict- 
est possible attention to the details of dietetics and general hygiene. 
The drugs that have been most helpful are nux vomica, arsenic, and 
digitalis sparingly. Moderate altitudes instead of at the sea-level 
are usually the best health resorts for sufferers from this disease. 
Hours of rest and exercise must be prescribed, the kind and amount, 
and never left to the patient's discretion. In exophthalmic goitre, 
there are always present some alternations in respiratory processes. 
Respiratory expansion is lessened in more than half of all cases that 
come under observation. Respirations are increased from twenty to 
thirty a minute. Increasing chest expansion is of great importance, 
as the physiology of respiration includes an influence upon the heart 
itself, upon the pulse, upon blood pressure, and upon the pulmonary 
circulation. To secure normal respiration, a somewhat novel plan 
■of treatment suggested itself to the author of the preliminary note. 

Deep respiratory movements by means of a variety of exercises 
that raise the arms, expand the chest, and cause deep and regular 
breathing, having been secured through the agency of an apparatus 
called the respirator, invented by Dr. Charles Fayette Taylor, which 
embodies in mechanical form Ling's principle of artificial respira- 
tion. The patient sits in a large chair or couch with a jointed mov- 
able back, grasping with the hands padded handles suspended from 
long levers placed at the back of the apparatus. These come to the 
patient's side in such a way that, when grasped by the hand, the 



DISEASES OF THE HEART 721 

"body is in perfect repose. Steam power is now turned on, the levers 
rise, the arms are drawn upward, the muscles of arm, chest, and abdo- 
men put upon the stretch, while the upper part of the cushioned 
"back moves and the chest is arched forward. The levers then descend, 
muscles relax, and the chest returns to its first condition. Respira- 
tions adapt themselves to the motion of the levers. When they rise, 
a deep and full inspiration is taken, the air being forced through in 
the gentlest manner to enter into and distend the alveoli. When the 
levers return, expiration is accomplished. 

Improvement is rapid, for the chief value of mechano-therapy in 
nervous or general constitutional disorders is to regenerate the mass 
of blood as a whole, to combat individual symptoms, and favorably 
to influence the mental state. The respirator possesses certain advant- 
ages over more active and voluntary movements. It exercises with- 
out fatigue, without strain upon the will power, and without the 
intervention and activity of another's personality. The action is 
entirely passive, as it is steam, an unseen and remote agent, that 
raises and drops the levers without noise, bustle, or conversation. 
The effects of systematized respiratory movements, as thus brought 
about, are, first, to increase the capacity of lungs for air ; second, to 
strengthen the elastic tissue of the alveoli ; to open up inactive air 
cells ; to promote free expectoration ; to loosen adhesions (pleuritic, 
etc.) j to stimulate pulmonary circulation, nourishing the lung sub- 
stance ; to rectify errors in the general circulation ; and to increase 
the aeration of the blood, thus nourishing the tissues and increasing 
metabolism. In the treatment of circulatory disorders many of 
Oertel's arguments to prove the efficacy of mountain climbing apply 
also to the use of artificial respiration, according to Ling's principles ; 
for Oertel's aim is to reduce the quantity of fluid in the body, to 
oxidize the accumulated fat, to effect a balance between the arterial 
and venous systems, and to strengthen the heart-muscles." 

At almost the same date that I read the above paper before the 
Illinois State Society, Dr. Sansom treated of the same subject in a 
lecture before the London Medical Society. 

Dr. Sansom took for his subject the consideration of certain cases 
of abnormal rapidity of the heart's action. He explained that he did 
not propose to consider any cases in which valvular or other organic 
heart disease was found to precede the signs of morbid acceleration. 



722 THE PRACTICE OF MEDICINE. 

He also excluded cases in which the condition of rapidity was asso- 
ciated with states of disease accepted by general experience as pre- 
disposing causes of such acceleration — such, for instance, as fever, 
the direct influence of certain germs, marked anaemia, hemorrhage, 
the operation of certain poisons and conditions of peripheral irrita- 
tion, such as the presence of undigested food in the alimentary canal, 
and the sometimes pronounced effects of intestinal worms. Dr. San- 
son! also excluded cases in which the acceleration was solely paroxys- 
mal ("paroxysmal hurry of the heart"), and also cases of palpita- 
tion, when such symptoms occurred in the case of a heart manifesting 
at the times when such palpitation was absent a normal rate of action* 
Restricting his review of cases to those not excluded for the above 
reasons, Dr Sansom employed the term " The Rapid Heart " to des- 
ignate the clinical condition met with. In some cases there was 
reason to believe the heart's action was quickened for very protracted 
periods. The limit of normal frequency was fixed by the orator at 
ninety in the adult ; he thought we must regard as morbid a fre- 
quency exceeding this , (In children the cardiac pulsations were nor- 
mally much more rapid, and were readily excited to a high degree 
of frequency by various intrinsic and extrinsic causes.) There were 
several classes of cases in which, in adult life, a long-persistent 
abnormal rapidity of the heart's action had been observed. In 
Graves's disease the pulse-rate might be 100 or 150, and under 
excitement might rise to 180 to 200 ; this acceleration of the heart's 
action was often the first sign, and might be for long periods the 
only manifest sign of the affection. The disease was serious and 
often fatal, and the chief cause of danger was in the cardiac involve- 
ment ; in fatal cases the heart was constantly found dilated and 
hypertrophied, but in no considerable degree. Another class of cases 
occurred in soldiers. Dr. J. M. Da Costa applied the term " irri- 
table heart " to designate an affection he observed among the men 
engaged in the American Civil War. Dr. Da Costa observed more 
than three hundred cases of persistently quick action of the heart, 
and many of them manifested no obvious departure from health ; 
the respiration-rate was not quickened pari passu with the pulse. 
" Rapid heart " had also been noticed in association with osteo- 
arthritis by Dr. Kent Spender, of Bath, who said : " The pulse 



DISEASES OF THE HEART. 723 

quickens with the earliest objective signs of osteo-arthritis, there is a 
gradual rise until the numerical frequency of 110, 115, or 120 is 
reached, and there is scarcely any physiological variation during day 
or night. And the cardiac tumult does not always subside, even 
when the osteo- arthritic phenomena come down ; a quickness and 
irritability continue which no medicine effectually controls." 

Cases of rapid heart without notable morbid association also 
occurred, and Dr. Sansom proceeded to consider such cases in detail. 
Dr. Bristowe had published nine cases, and excluding one of these 
on account of the co-existence of organic (valvular) disease, and 
another because the symptoms were more strictly paroxysmal, seven 
cases remained. In several of Dr. Bristowe's cases the patients were 
unconscious of anything abnormal. Yet five out of the seven cases 
died with signs which seemed to show that the affection was in casual 
relation with the deaths. One case ended in albuminuria and death 
after three weeks. In another, after undue rapidity of heart — the 
rate being from 200 to 260 — had continued for six weeks, agonizing 
pain at the pericardium supervened, and the patient died with symp- 
toms of pulmonary obstruction and failing heart. One of Dr. Bris- 
towe's cases was ushered in by an attack supposed to be a sunstroke. 
Of six cases mentioned by Dr. Broadbent, one became hemiplegic 
and another died in convulsions. In one fatal case recorded by Dr. 
Bristowe, the heart was found post-mortem to be somewhat dilated 
and hypertrophied, but both the valves and the walls were healthy. 
In a case noted by Dr. Dreschfeld and Maguire, in which there was 
a history both of syphilis and of alcoholic excess, the heart was large 
and its tissue degenerated. The question arose whether the affection 
was one of the myocardium or of some portion or portions of the 
nervous system. Dr. Bristowe thought it had no special connection 
with cardiac disease, and that dilatation and hypertrophy of the 
heart, when occurring independently of valvular mischief, were the 
slowly-developed consequences and not the causes of the disturbance. 
On the other hand, Dr. Samuel West regarded cases of paroxysmal 
hurry of the heart as due to an organic lesion of the muscular sub- 
stance, which might be in some cases a form of chronic interstitial 
myocarditis, consequent, perhaps, on rheumatic pericarditis or on 
syphilis, and thus related to fibroid disease of the myocardium. 



724 THE PRACTICE OF MEDICINE. 

BRADYCARDIA, or Slow Action of the Heart. 

The cases hitherto recorded of " slow heart " and the inferences 
derived from them are not altogether satisfactory, as many errors 
have arisen owing to the pulse having been only taken at the wrist 
and not compared with the apex-beat. Dr. Riegel has made observa- 
tions on 1,047 patients whose hearts beat less than sixty times per 
minute. Such a condition he terms bradycardia. He divides his 
cases into two large groups : 

(1) Physiological bradycardia. By this Riegel understands a 
slowing of the heart's action, caused by, or in connection with, some 
physiological condition. Under this head would come the " slow 
heart," occurring in puerperal states, also that which is found in cases 
of starvation, and finally, the bradycardia which is sometimes observed 
as a constitutional peculiarity. Riegel here remarks that many of 
the cases of this kind which have been reported are greatly open 
to question, as some of them were obviously due to some patholog- 
ical cause. 

(2) Pathological bradycardia. There are several varieties under 
this head : (a) the slowing of the pulse noticed in convalescence from 
a febrile affection. More than a quarter of the whole number of 
cases were of this kind. They were most commonly observed after 
recovery from croupous pneumonia ; then, in order of frequency, 
after typhoid, erysipelas, and acute rheumatism. Traube attributed 
this phenomenon to a state of general exhaustion, (b) Bradycardia 
in diseases of the digestive tract. In this division were 379 cases. 
It was most frequently noticed in affections of the stomach (ulcer, 
carcinoma, and dilatation). Such a result might have been inferred 
from physiological experiments ; for in animals an increase of arte- 
rial tension with diminution in frequency of the pulse takes place 
when the stomach is submitted to electric, mechanical, or thermic 
excitation, and is caused by a reflex action of the vagus. The slow 
pulse of icterus probably depends on the paralyzing action upon the 
cardiac ganglia by the bile acids in the blood. When occurring in 
cases of peritonitis, the bradycardia is probably of the nature of 
those cases described in the first division. 

(3) Bradycardia in diseases of the respiratory organs. In this 
class were eighty-seven cases. Some of them were during conva- 



DISEASES OF THE HEART. 725 

lescence from pleurisy ; others from haemoptysis, or after the with- 
drawal of a large pleural exudation. 

(4) Bradycardia in cases of disorders of the circulatory organs 
(forty-seven cases). This phenomenon appeared in fatty degenera- 
tion of the heart and when the coronary arteries were ossified, but 
it was never found as a constant symptom of any one disease of the 
heart ; it more often occurred when the heart was flabby and insuf- 
ficiently nourished. 

(5) Slow heart in diseases of the urinary organs (sixty-four 
cases). Acute nephritis was the most common disease in which it 
was found ; the slowing of the pulse was always accompanied by 
increase of arterial tension, and was often the earliest sign of the 
retention in the blood of the urinary constituents, thus denoting the 
commencement of uraemia. 

(6) Bradycardia as a result of poisoning. Riegel noticed it in 
three cases of lead-poisoning and in five cases of chronic alcoholism. 

(7) A pulse under sixty per minute was noticed in twenty-seven 
cases of anaemia and chlorosis, in one case of extreme anaemia after 
lead-poisoning, and in three cases of diabetes. 

(8) Bradycardia in diseases of the nervous system (ninety- three 
cases). In many of these cases it was thought to be due to reflex 
vagus action. In some instances of disease of the central nervous 
system it was probably caused by direct vagus action ; in others Rie- 
gel ascribed the symptom to disturbances of the circulation and 
blood-pressure in the brain ; and in the remaining number of cases 
no definite action could be distinguished. 

(9) Bradycardia in other diseases. Under this head were seven- 
teen cases of extreme fatigue and exhaustion, one case of sunstroke, 
twelve cases of skin diseases, and seventeen of painful affections of 
the muscles. 

Dr. I. E. Atkinson, of Baltimore, writes as follows on this sub- 
ject: "Bradycardia, or unduly slow heart-action, is a symptom 
observed in a variety of disorders apart from those in which there is 
manifest disturbances of the central nervous system. It is not infre- 
quently observed during convalescence from acute febrile disease, 
when it disappears, usually with the re-establishment of health. Much 
more uncommonly it develops at the outset or during the active period 
of such disease. It is thus rarely observed during an attack of acute 



726 THE PRACTICE OF MEDICINE. 

articular rheumatism. In the former case it probably depends upon 
pericarditis or endocarditis, whereby the innervation of the heart is 
impaired. In the latter case it is probable that in some instances 
it is still due to these causes, though it may also depend upon the 
same influences that excite it during convalescence from other acute 
specific febrile diseases, and which are apparently not inflammatory." 
Dr. D. W. Prentice, in a paper on " Slow Pulse" ("Therapeu- 
tic Gazette ") says : u The causes which produce slow pulse may be 
classified as follows : 

(1) " Diseases or injuries to the nerve-centres, producing either 
irritation of the pneumogastric, or paralysis of the sympathetic (accel- 
erator) nerves of the heart. 

(2) Diseases or injury of the pneumogastric nerve, increasing 
its irritability. 

(3) Diseases or injury of the sympathetic nerves of the heart, 
paralyzing them. 

(4) Diseases of cardiac ganglia, by which the influence of the 
pneumogastric nerve preponderates. 

(5) Disease of the heart-muscle (degeneration), whereby it fails 
to respond to the normal stimulus. 

(6) The actions of poisons, as lead or tobacco, either on nerve- 
endings or nerve-centres. The poisons generated in salt fish. Also 
the poisons of certain febrile diseases ; algid pernicious fever. 

In many of the cases collected in connection with this report, the 
pathological appearances were a result of the slow pulse rather than 
the cause. 

" In looking up the literature of " Slow Pulse " in the library of 
the surgeon-general's office, I find it more extensive than I had anti- 
cipated. And I wish here to pay a tribute to this magnificent 
library, and its admirable management for convenience of consulta- 
tion. Without its " Index Catalogue " it would have been simply 
impossible for me to have brought together the cases in this abstract. 
The following is a brief summary, according to the supposed causes 
or pathological conditions : 

(1) Autopsies are given in twenty-seven cases. 

(2) Diseases of the brain, eight cases. 

(3) Diseases or injury of the cervical vertebrae, eleven cases. 

(4) Epilepsy, convulsions, seven cases. 



DISEASES OF THE HEART. 727 

(5) Heart disease, nine cases. 

(6) Ossification of aortic valves and coronary arteries, three cases. 

(7) Starvation and exhaustion, loss of rest, convalescence, three 
cases. 

(8) Lead-poisoning, nervous shock, pernicious fever, three cases. 

(9) Poisoning by salt fish(?), one case. 

(10) Cholera morbus, indigestion, three cases. 

(11) Acute febrile disease, four cases ; also nine cases referred 
to by Drs. Halpin and Mease, ' Dublin Medical Journal,' xiii., Feb- 
ruary, 1849. 

(12) Pericarditis, two cases. 

(13) Cerebral syphilis, two cases. 

(14) Rheumatism, one case. 

(15) Sunstroke, one case. 

(16) Xot given, thirty-seven cases. 

The slowest pulse was in Case lxxix., when it fell to three per min- 
ute. The next slowest pulse was in Case lxxxiii., where it fell to 
four per minute for four minutes during an attack of syncope, and 
once did not beat for thirty-five seconds, and again for twenty-five 
seconds. The next slowest pulse was seven per minute, in Case xxxvi. 
In Case xxxviii. it fell to nine per minute. In reviewing these cases 
of slow pulse, it is evident that the pathological conditions are very 
diverse, but they can probably all be referred to some one of the 
classes given above. Dr. A. Flint, in his article on the subject in 
the "American Practice," vol. xiii., 1876, very appropriately divides 
them into two varieties, namely : 

(1) Functional slow pulse. 

(2) Organic slow pulse. 

Organic slow pulse, including all cases in which organic changes, 
principally of the nerve-centres or the heart, are evident during life 
or demonstrated by autopsy. 

Functional slow pulse, embracing all cases in which no such lesions 
can be found. 

It will be evident by a glance at the summary given above that 
nearly one-half of the cases belong to the " functional " division. 
This fact has a special significance, because it is equivalent to a con- 
fession that in nearly one-half of the cases we are ignorant of the 
true cause of the condition. The same, however, is true of many 



728 THE PRACTICE OF MEDICINE. 

very common diseases to which we give a name from certain groups 
of symptoms, as small-pox, measles, yellow fever, etc. On the same 
grounds, perhaps, " functional slow pulse " may deserve the dignity of 
a name as a distinct disease. A large number of the cases corre- 
spond very closely in their clinical history to the case which has given 
a text for this paper. Prodromes of malaise, weariness, and exhaus- 
tion. Fainting fits, with momentary unconsciousness, the pulse 
becoming slow, from a minimum of three per minute to forty per 
minute, averaging from eighteen to forty per minute. The fainting 
fits keep pace in frequency and severity with the low rate of the 
pulse. The attacks are remittent in character, lasting from a few 
days to several weeks, then remitting for a similar interval, to return 
with increased severity. The course here outlined continues until 
the individual dies in a syncopal attack more severe than any pre- 
ceding, from utter failure of the heart to propel the blood through it. 

No organic disease can be detected to account for the slow action 
of the heart. The symptoms observed are the result of the deficient 
circulation, and many of the appearances found in autopsy are from 
the same cause, especially where the case has been prolonged. 

Treatment is purely symptomatic, and thus far has not been 
encouraging. 

Prognosis is unfavorable. In the cases recorded all, or nearly 
all, have terminated fatally, death occurring from sudden syncope. 
The pathology is entirely in the dark, but further study into the 
functions of the cardiac nerves and ganglia in their relations to the 
heart-muscle promises to throw light on the subject. 

It is possible that * functional slow pulse ' may be a disease of the 
cardiac ganglia." 

Treatment. — The medicines capable of causing slow pulse enu- 
merated by Dr. Snader (Repertory of Heart Symptoms in " Hale's 
Lectures on Diseases of the Heart") are very many, but not all can 
be relied upon as remedies for this condition. Those which I con- 
sider trustworthy are : aconite, adonis, amygdala amara, apocynum 
cannabium, asparagus, baryta, cactus, caffeine, cannabis indica, chel- 
idonium, convallaria, colchicum, digitalis, euonymin, gelsemium, hel- 
lebore, helonias, hydrocyanic acid, iberis, bromide of potassium, cyan- 
ide of potassium, nitrate of potassium, kalmia, lobelia, lycopus, cyan- 
ide of mercury, naja, nicotine, oleander, opium, plumbum, secale, 



DISEASES OF THE HEART. 729 

Scutellaria, spigelia, kola, strophanthus, squilla, veratrum album and 
veratrum viride. All these cause a slow pulse, primarily ; but the 
character of this slow pulse is not the same with all. In the " Rep- 
ertory " referred to, the characteristic pulse of each is given very 
accurately. In selecting the remedy there is one point which should 
not be lost sight of, namely, that if the condition causing the slow 
pulse is a primary affection, only the above medicines will be effect- 
ive ; and if the slow heart and pulse is a secondary affection, other 
medicines should be consulted. I mean those which primarily cause 
a rapid pulse and rapid heart-beat, and secondarily a slow beat from 
exhaustion after previous over-stimulation. As our " Repertories " 
are now constructed it is very difficult for the average practitioner 
to ascertain what medicines cause a rapid pulse as a primary effect, 
because no distinction is made between the primary and secondary 
effects of drugs. Under the head of " rapid pulse " Snader places 
all the medicines I have mentioned above, and twice as many other 
drugs. I admit that our knowledge is incomplete, yet I venture to 
name a few belonging to the class that have this primary action, 
namely : amyl nitrite, ambra, carbonate of ammonium, apis, arsenic, 
asafoetida, atropine, aurum, anhalonium, belladonna, bryonia, canna- 
bis indica, cinchona, chininum sulph., coca, ferrurn, glonoine, hyos- 
cyamus, ignatia, jaborandi, phosphorus, physostigma, rhus toxico- 
dendron, sanguinaria, sumbul, nux vomica, strychnine, strammonium, 
turpentine, and tartar emetic. In selecting a remedy for slow pulse 
and slow heart, the pulse-beat and heart-beat should be synchronous, 
but only few provers observed the pulse and the heart-beat at the 
same moment. Then, again, the elements of irregularity and inter- 
mittency should be left out. A drug like laurocerasus may be selected 
from this one symptom, but if the slow heart be due to bile-acids 
in the blood, it will do no good ; while if euonymin is given it removes 
the slow pulse by bringing about a normal activity of the hepatic 
cells. If possible we should ascertain the cause of the slow heart, 
and select the remedy accordingly. If the slow heart occurs dur- 
ing the puerperal state it is a secondary condition and usually requires 
ignatia, cimicifuga, arsenic, strychnine, or belladonna. If from 
inanition, food and stimulants with nux vomica are needed. If it is 
really constitutional, as it was in the case of Napoleon, drugs should 
not be given at all. If the slow pulse occurs during convalescence 



730 THE PRACTICE OF MEDICINE. 

from acute fevers, arsenic, cinchona, quinine, mix vomica, strychnine, 
phosphoric acid, or sanguinaria are needed. When it occurs from 
profound neurasthenia (cardiasthenia), picric acid, phosphoric acid, 
phosphorus, and strychnine are to he relied on. If fatty degeneration 
of the heart is suspected phosphorus is the most homeopathic remedy. 
Iodoform has caused that condition. But the arseniate of strychnine 
should be given in any case to keep up the tonicity of the muscular 
fibres. 

In renal diseases slow pulse indicates impending uraemia. In such 
case we must eliminate the constituents of the urine from the blood 
before we can expect the heart's action to improve. Here diuretin, 
apocynum, and juniper should be given. In a majority of cases we 
cannot find the cause of the slowness of the heart. We must then 
select the medicine from its close similarity to the subjective symp- 
toms. 

I have treated in all perhaps fifty cases of slow heart. Of these 
I have removed the symptom in three-fourths. The chief medicines 
in all the cases cured were digitalis, strychnine, and sanguinaria. 
The usual dose of digitalis was five to ten drops of the lx dilution ; 
of strychnine, from l-5000th to l-50th of a grain, and of sanguin- 
aria, one to five drops of the lx or tincture. The dose was repeated, 
usually three times daily. 

For the fainting fits which occur in some cases, ammonia, amyl 
nitrite, and glonoine are most useful and often save life. It is not 
safe to use electricity for we do not know to a surety what it will do. 
In one case in which an expert used it on one of my patients it 
seemed to arrest forever the action of the heart. In a case related 
by Dr. Prescott the patient got more relief from bromide of ammo- 
nium in large doses during the paroxysm of fainting and anxiety 
than from amyl or glonoine. If the patient's heart is very weak as 
well as slow great caution should be used in his exercise. No climb- 
ing of stairs or hills, no sudden change of posture, and no running. 
The meals should be frequent and small. All sudden and violent 
emotions should be avoided. Alcohol is injurious, and should be 
carefully given in emergencies, for it always weakens the heart in 
the end. A small cup of black coffee is better. If any wine is used, 
Tokay and wine of coca are the best. Lying on the left side and 
straining at stool and lifting should be forbidden. 



DISEASES OF THE HEAMT. 731 



THE SENILE HEART. 

A broad definition of senile heart would be, the heart of old age. 
But old age is a relative term. Senility does not always come with 
years. Gladstone is as young and his heart as sound as that of 
many of his contemporaries of half his age. There is a premature 
senility of the heart as of any other organ. The tissues of the heart 
and its nerve supply may wear out and undergo degeneration, while 
all the other organs and tissues are comparatively sound. 

Senility of the heart may be due to degeneration of its muscular 
fibres, of its nerves and ganglia, of its arteries, or of its nerves of 
innervation from the medulla or spinal cord. It would not do to 
restrict the definition to the heart of extreme old age which is worn 
out, together with all other parts of the body — a general decay for 
which there are no remedies — only temporary palliatives. 

Dr. Balfour, of Edinburgh, the only author who has written exten- 
sively on this subject, says, " the senile heart is generally a gouty 
heart "; but that is not so at present in this country, although it may 
be in England and on the Continent. The American senile heart is 
generally premature and caused by the morbid mental and physical 
activity of business life here. The degeneration usually begins in 
the inhibitory nerve and not in the heart itself. 

" We can never hope," says Balfour, " to rejuvenate the old, but 
age and suffering are not synonymous terms, and the absence of suffer- 
ing does much to compensate for the loss of youth. The heart is the 
one organ of the body whose sufferings are most apt to disturb the 
equanimity even of the most imperturbable. We know that with 
each pulsation life and intelligence are flashed to the farthest out- 
post of our frame, and we also know that if the heart-beats falter 
for a second or two we fall to the ground, pale, limp, and almost 
inanimate. Hence palpitation, intermission, irregularity, and tremor 
cordis, all of which make themselves disagreeably perceptible to 
our senses, appeal most forcibly to the imagination of the patient, 
and bring him more certainly to the physician than cardiac ailments 
of more serious import but less obtrusive character. Such symptoms 
occurring in early life may betoken physical impairment, but are 
more commonly indicative of mere nervous instability; neither of 
these may be of much consequence. In advanced life, however, or 



732 THE PRACTICE OF MEDICINE. 

at any time after middle life, there is always some physical impair- 
ment of the organ concerned, and there is also the possibility that 
this may be primarily due to failure of the trophic nerve centres. 
That this cannot be generally or even often the case may be regarded 
as proved by the marked improvement that follows treatment in the 
majority of cases. A primary affection of the nerve centres must, 
however, be regarded as a quite possible cause, and to it may prob- 
ably be ascribed the intractability of some at least of those cases we 
meet with. Senile diseases are always degenerative, and tend to 
precipitate the natural termination of life. In them the object of 
treatment is not quite the same as it is in diseases of earlier life ; 
we no longer hope for complete restoration, but we expect to be able 
to remove suffering and to check decadency, and, so far as the heart 
is concerned, there is good reason for believing that we are frequently 
successful in the attainment of both of these objects. Indeed, such 
is the recuperative power of this organ, that even although the aver- 
age limit of mortality be long over-passed, we can often remove dis- 
comfort, and avert decadency so completely as apparently to effect 
a cure of what is of necessity incurable. In this fight with mortal- 
ity it is not medicines, though these, too, have their place and power, 
so much as attention to the little things of daily life, the little things 
of eating, drinking, and doing that gradually turn the scale of health 
for evil or for good ; and herein lies one of the great difficulties in 
the way of successful treatment, for the physician has certain regu- 
lations to lay down which, almost of necessity, are opposed to the 
habits of a lifetime. But where science is opposed to lifelong habit, 
there is never any doubt as to which ought to yield." 

It is well to remember, however, that all affections of the heart 
found in the old are not necessarily senile in origin. 

Another point to be remembered is, that even when an existing 
affection of the heart is certainly senile in character, in the sense of 
having come on primarily and insidiously after middle life, and pos- 
sessing the ordinary characters of a heart strain from internal causes, 
the symptoms complained of do not always depend upon the heart's 
affection, even when they seem to be distinctly cardiac in their nature. 
For instance, great breathlessness accompanying a heart with distinct 
and free mitral regurgitation, as revealed by a loud mitral murmur, 
is by no means always due to the heart affection, or to be relieved 



DISEASES OF THE HEART. 733 

by ordinary cardiac tonics. Many such cases are due to anaemia 
arising from some obscure source, such as melanaemia from various 
causes, or even epistaxis, which, apart from occasional severe out- 
bursts, may be attended by persistent oozing from the posterior nares, 
trifling in itself, serious from its continuance. Obscure malignant 
disease of some internal organ is also no infrequent cause of anaemia, 
which may not only give rise to great breathlessness on exertion, but 
also to emotional or reflex attacks of nocturnal breathlessness, often 
slumped under the name of cardiac asthma. Yet the cardiac action 
in many such cases may be full and strong, the existing lesion per- 
fectly compensated, and the subjective symptoms largely in excess 
of the objective cardiac phenomena. In all such cases it is the con- 
dition of the blood we must treat, not that of the heart. We must 
do our best to remove the anaemia, and content ourselves with watch- 
ing the heart and treating it as occasion arises. Even oedema of the 
lower limbs, so often found as an early indication of cardiac failure, 
not infrequently arises from the state of the blood alone, and not 
from the heart at all. We are all accustomed to note the condition 
of the blood as all-important in the breathlessness and oedema of 
spanaemic patients in early life, in whom there is probably no great 
indication of any affection of the heart ; but in cases of marked valv- 
ular lesion in advanced life we, as a rule, are scarcely prepared to 
look beyond this lesion, and the condition of the blood is too often 
neglected, to the great detriment of the patient. And yet there are 
so many serious causes of impoverishment of the blood in advanced 
life that our prognosis can never be safe, nor our treatment beneficial 
until the case has been duly considered from every point of view. 

Simple irritability is the earliest indication of what I may call 
advancing senility in the heart. The patient complains of uneasi- 
ness in the cardiac region, at times amounting to actual pain felt in 
or around the heart, but strictly localized and not shooting or dart- 
ing in any direction. Along with this there may be fits of palpita- 
tion, in the form of rapid but not usually forcible action, which come 
on after exertion, such as running rather quickly up-stairs, upon any 
excitement or sudden emotion, or during the night from reflex causes, 
mostly of gastric origin ; or there may be fits of tremor cordis com- 
ing on suddenly, without warning and apparently without cause. 
The rhythm of the pulse is occasionally and temporarily irregular 



734 THE PRACTICE OF MEDICINE. 

m force and frequency ; or it may simply intermit, drop a beat at 
irregular intervals ; or this intermission or dropping of a beat may 
occur at regular intervals of longer or shorter duration, and this 
regular intermission at irregular intervals, and mostly as the result 
of emotion or of gastric disturbance. 

These phenomena are always indicative of cardiac debility, which, 
left to itself, sooner or later leads to dilatation of the heart, as well 
as to the other serious symptoms which we find associated with senile 
degeneration of that organ. These symptoms depend upon struc- 
tural alternations in the heart itself, in its vascular and nervous con- 
nections, as well as in the nutritive fluid, the blood. 

Thus one patient may for years complain of nothing but an occa- 
sional soreness in the cardiac region, and at last break down sud- 
denly from neurasthenia, as he flatters himself, really from cardiac 
dilatation, which may end in dropsical asthenia in the usual way. 
Not infrequently it may terminate in a fatal attack of angina of the 
ordinary form, or occasionally in that form of sudden cardiac failure 
which may be termed angina sine dolore. Another patient may only 
complain of occasional intermission or fluttering tremor cordis which 
annoys him by its recurrence, and such a case perhaps terminates 
suddenly in an attack of angina sine dolore more often than in any 
other way ; while there are others in whom intermission or irregu- 
larity of the pulse or tremor cordis persist for many years without 
any apparent detriment. But my own experience is, that unless 
remedied by treatment, such cases always ultimately develop serious 
cardiac symptoms, though this may be delayed even to hoary age. 
Many such patients do not seem to suffer in any way from their ail- 
ment ; it seems somehow completely to escape their cognizance ; 
others, again, suffer very much from the feeling of insecurity engen- 
dered by their malady. 

With the cardiac irregularities and intermissions of the aged 
there is, however, so often a faltering of consciousness, or of muscular 
power, that as a rule paralysis or brain failure is dreaded much 
more often than failure of the heart. The senile heart is a term, as 
we have seen, which comprehends many symptoms and a variety of 
signs, but which is at bottom a cardiac failure based upon malnutri- 
tion, with whatsoever symptoms that malnutrition may be associated, 
or by whatsoever signs it may be revealed. It is therefore of the 



DISEASES OF THE HEART. 735 

utmost importance to determine the cause of this failure, and to 
ascertain the source of the malnutrition on which it depends. In all 
these cases the objective symptoms are always the most valuable and 
most to be relied upon ; the subjective symptoms must also be col- 
lected and collated, and much information is thus obtained, but in 
no case is this information so important or so reliable. 

(The pulse is an important factor in the diagnosis and treatment. 
I refer to my articles on " Low Arterial Tension " and " High Arte- 
rial Tension.") 

Dr. Balfour gives the following directions for diet : " Cases of 
senile heart may be grouped for dietetic purposes under two distinct 
heads : First, those who are over their normal weight, who are 
breathless with occasional irregularity of the heart, and without 
marked signs of cardiac dilatation ; and, secondly, those who are at 
or above their normal weight, and who suffer very considerably from 
cardiac disturbances of various characters, also with or without very 
evident signs of dilatation of the heart." 

[The first class of cases are usually dubbed cases of fatty heart, 
and the diet laid down in the article on " Obesity " will be suitable. 
The second class are grouped under the ordinary heading of cardiac 
disease, and the diet recommended for " Leanness " should be ad- 
vised.] 

" The first point of importance in regard to all cases where diet- 
ing and dietary come into question is to divide the day properly, so 
that there may be a sufficient interval between each meal. In health 
the stomach empties itself usually three to four hours after a meal, 
and requires a rest before more food is ingested. In those having 
weak hearts and feeble circulations the digestion is bound to be 
somewhat slower, hence the first rule to lay down is: not less than 
five hours between each meal. This allows of three statutory meals 
in the day, with a sufficient interval for the digestion of the last 
meal to be pretty well advanced before retiring to rest, which tends 
to insure a quiet and restful night. The next matter of importance 
to remember is, that the ingestion of solid food into a stomach still 
digesting a former meal arrests that process and provokes flatulence, 
hence the second rule to be laid down is : no solid food of any kind is to 
be taken between meals. This rule must be absolute ; not even a mor- 
sel of cake or biscuit, or any similar trifle, is to be ingested between 



736 THE PRACTICE OF MEDICINE. 

meals. There is nothing so destructive of gastric comfort as the contin- 
ual pecking induced by gouty bulimia. This prohibition does not ex- 
tend to water, which should be taken hot rather than cold ; and of 
this hot water half a pint may be sipped if desired about two or three 
hours after a meal. Taken in this way it does not disturb the diges- 
tion, it washes out the stomach, and passes speedily through the kid- 
neys without raising the blood-pressure. But as little fluid as pos- 
sible should be taken with meals. The third important rule is, that 
all invalids should have their most important meal in the middle of the 
day, and should only have a light meal in the evening. Next follows 
the important question of quantity and of quality, matters very closely 
connected one with the other ; for the isodynamic value of one kind 
of food compared with that of another depends upon their respective 
powers of producing energy. 

" Lewis Cornaro, perhaps the most celebrated of abstinents, re- 
duced his solids to twelve ounces, and his fluids to fourteen ounces 
of new wine in the day, and continued to maintain himself in per- 
fect health till his death, which happened when he was over one hun- 
dred years old. At one time some of his friends persuaded him to 
take daily a couple of ounces more of solids and the same of wine, 
but this trifling excess made him ill. No doubt Cornaro was an idle 
man, and did not exert either his body or his mind, and he took his 
food in the shape of bread, meat, and eggs, and his drink as new wine, 
all highly nutritious articles of diet ; so that, although as regards 
mere quantity Cornaro's diet appears to be scarcely a bare subsist- 
ence, yet having regard to its composition it was, as it turned out 
to be, perfectly sufficient. It is but rarely if ever that we can pos- 
sibly desire to restrict the diet of our patients so rigidly as Cornaro 
did his own ; but as none of our patients are at work, and many of 
them probably obese, it is a diet worth remembering as one upon 
which its recipient lived in perfect health, not for a month or two, 
but for more than sixty years. The knowledge of this suffices to 
make one rather callous when assailed by complaints of being 
starved ; still it is very desirable to watch all obese patients lest they 
should come down too rapidly, and to see that all others maintain 
their equilibrium in comfort. We must, therefore, weigh our patients 
occasionally. 

" Alcohol in one or other of its various forms is often recom- 



DISEASES OF THE HEART. 737 

mended as a fillip to a weak heart, or an aid to a feeble digestion, 
and so it is pro tempore; but there is no greater mistake than to 
continue it as likely to benefit. Alcohol always tends to enfeeble a 
weak heart, and to lessen the power of a feeble digestion, when con- 
tinued for any length of time, and ought to be given up. I once 
knew a lady who suffered much from a feeble, irregular heart, partly 
hereditary and partly acquired, who obtained so much relief from the 
use of alcohol that she not only recommended frequent 'nips' to all 
similar sufferers, as a specific, but was in great danger herself of be- 
coming a victim to immoderate indulgence. By and by, under other 
influences she was led to give up the use of alcohol entirely, and she 
has often assured me that the sipping of hot water was quite as stim- 
ulating to the heart at the time, and ultimately far more strengthen- 
ing than the use of alcohol. From what has just been said it may 
be gathered that I never advise alcohol in any form for such cases, 
and where old habits are too strong I recommend that only light 
claret or light and white hock should be taken with dinner, and of 
these not more than one or at the most two glasses. Whisky, as one 
of the purest spirits, is also one of the safest, being utterly devoid of 
the slightest tendency to develop gout, a tendency which even light 
claret is not altogether free from unless used most sparingly. 

"Tobacco is a narcotic — a powerful narcotic, not to be abused 
with impunity. The tobacco heart is a well known and easily recog- 
nized form of cardiac irregularity, for which there are many pallia- 
tives, but only one cure — to give up tobacco. Cigarette smoking 
and inhaling the smoke into the lungs is the most deadly mode of 
using the drug, and by far the most difficult habit to break. Other 
forms of tobacco smoking — pipes and cigars — are very much alike, 
and their influence for evil depends upon the quantity smoked, and 
in a considerable degree, also, upon the quality of tobacco. Withal 
it takes a good deal of tobacco to hurt some people. The last patient 
w T ho was brought to me for tumbling on the street from this cause, 
was in the habit of inhaling fifty cigarettes daily; he had a pasty, 
sodden look, and I gave him to understand that unless this bad habit 
was given up, his life was not likely to be long. Mr. Syne used to 
say : 'Young men, bubbling over with energy, both can and do smoke 
more than they ought; but old men cannot smoke with impunity.' 
This is the rule, to which there are many exceptions ; a few of these 

47 



738 THE PRACTICE OF MEDICINE. 

are real — few can smoke with impunity, others conceal their suf- 
ferings." 

" With a weak, feeble, and irregular heart it is wise to give up 
tobacco altogether, though it is possible for many, not for all, to con- 
tinue to smoke moderately to the end, if the smoking be restricted 
to a single pipe or cigar in the evening. There is no habit in which 
idiosyncrasy plays so great a part as in tobacco smoking ; let every 
man be fully persuaded in his own mind. The drugs useful in the 
senile heart in all its forms are but few in number, but of extreme 
value. We may easily multiply the number, but with the multipli- 
cation the value is not increased. All varieties of the senile heart 
are forms of heart failure with complications ; the treatment must 
therefore be tonic, with modifications." 

Dr. Balfour's treatment, given below, is far in advance of the 
usual regular medication. His use of drugs are based on their phys- 
iological effects, as understood by the old school. It is well known 
to those conversant with my writings, and my theory of primary and 
secondary action, that nearly all the medicines which he calls cardiac 
tonics are really secondarily homoeopathic. Digitalis, for instance, 
if pushed beyond its primary action, causes finally a condition of 
cardiac debility similar to that for which it is prescribed by all reg- 
ular physicians. They have no use for the primary effects of digi- 
talis, i. e., they never give it for a strong, spasmodic action of the 
heart, with contracted arterioles, vertigo, etc. 

Digitalis, according to Balfour, " is the chief and most thoroughly 
reliable cardiac tonic ; where any drug can act at all it will never 
fail, and, carefully managed, there is no risk of any danger or dis- 
comfort in continuing it for as long as may be needful. Under the 
influence of digitalis the whole muscular system becomes more elas- 
tic, each muscle both extends and contracts more perfectly, and as 
the heart gets the benefit of all the blood in the body passing through 
it, the drug affects it earlier and more powerfully than the other 
muscles. The muscular coat of the arterioles gets, also, proportion- 
ately larger share of what is going, and the effect of the more perfect 
contraction of both heart and arterioles is to raise the blood- pressure 
by improving the circulation, increasing the amount of blood in the 
arteries, and diminishing the stagnation in the veins. The result of 
this improvement of the circulation is to cause the absorption, from 



DISEASES OF THE HEART. 739 

the interstices of the tissues, of the fluid which has been slowly accu- 
mulating there under the influence of venous remora. The absorp- 
tion of this soakage, which has nowhere appeared as dropsy, increases 
the flow of urine and proportionately diminishes the weight of the 
body, quite apart from any interference with its metabolism. Al- 
though digitalis improves the extension of a muscle as well as its 
contraction, it does so by improving its elasticity and restoring its 
tone ; hence, even though the diastole of a dilated heart may be pro- 
longed, the ventricle is not filled any fuller, but rather less so, and 
this is especially well seen in cases of aortic regurgitation, where, in 
spite of a prolonged diastole, the ventricle is found to diminish in 
size as its beats increase in force." 

My experience with digitalis agrees with that of Balfour. In the 
treatment of a weak and dilated heart I always give a material dose, 
just enough to set up its physiological but mild primary action. Bal- 
four prefers the alcoholic tincture for the reason that it does not con- 
tain digitonin, a principle antagonistic to digitalin and digitoxin. 
Digitonin is not soluble in alcohol, the two latter are. But Balfour 
and all practical physicians are aware that in cardiac dropsy the 
infusion will act favorably when the tincture will not. There must 
therefore be some potent influence in digitalin, possibly on the kidneys, 
not possessed by the two other alkaloids. When we have no dropsy to 
deal with I also prefer the tincture. Balfour prefers Nativelle's gran- 
ules, which are said to be composed almost entirely of digitoxin, 
which has an action precisely similar but perhaps more powerful than 
digitalin. I have never used them, but I get good results from tab- 
let triturates of the 3x trituration of crystalized digitalin, each one 
containing l-1000th of a grain. Nativelle's granules each contain a 
quarter of a milligramme (about 1-25 Oth of a grain). Balfour gives 
one granule every twenty-four or forty-eight hours, and says he has 
never found a heart requiring a smaller dose. 

He believes it necessary in order to build up a senile and dilated 
heart to continue the use of digitalin for several months. I believe 
that the reason why physicians so often fail to get good effects from 
digitalis in the chronic weak heart is that they do not continue its 
use long enough. If they do not find the heart grow stronger 
and more regular in a week or two, they abandon the medicine. 
They do not consider that a heart that has been growing weak for 



740 THE PRACTICE OF MEDICINE. 

years requires months to attain any decidedly permanent improve- 
ment. 

Baryta muriatica ought to be one of the best remedies for the 
senile heart when the weakness depends on degeneration of its arter- 
ies and its muscular fibres. The 2x trituration in two-grain doses 
three times daily for several weeks should be persisted in. 

Aurum muriaticum in alternation or combination with nitrate 
of strychnine 2x trituration is a potent restoration of the senile heart 
when it is dilated and deficient in innervation. 

If the dose of digitalis be moderate, this increase of tone, accom- 
panied by an improvement in nutrition, due to a more effective flush- 
ing of the heart with a more perfect nutrient fluid, may be kept up 
and continued indefinitely for months or years without any fear of 
its action going further. But if the dose of digitalis is in excess of 
what is required, the contraction of the heart goes on increasing till 
the symptoms of digitalis poisoning occur, the heart ultimately com- 
ing to a standstill in systole. It is the duty of the physician to see 
that the happy mean is not exceeded ; and there is the less tempta- 
tion even to approach excess in treating the senile heart, and there 
is first of all, certainly, some risk of rupturing arteries which may 
be atheromatous by the rise of blood-pressure due to the drug, though 
I believe this risk is infinitesimal ; and, secondly, because we can 
scarcely ever hope to contract and cure a dilated and hypertrophied 
senile heart. 

There is only one other member of the digitalis group which has 
any pretentions to rival digitalis itself, and that is strophanthus, but it 
is so much more uncertain in its action than the leading member of 
its group, that I never felt inclined to displace our indigenous drug in 
its favor. Moreover, if, as some experimentalists say, its action is 
chiefly expended on the papillary muscle, while there is either no in- 
crease, or ' only a very slight increase in the force of the contractions 
of the ventricular wall,' it would seem from its action alone to be 
scarcely the drug to trust to in the class of cases I am now speaking 
of. There is no doubt, however, that the strophanthus is a power- 
ful heart tonic, and it has more than once happened to me that the 
heart of a senile patient apparently moribund has been roused to 
action by the tincture of strophanthus when it appeared to be already 
beyond the reach of digitalis ; and as strophanthus is readily soluble 



DISEASES OF THE HEART. 741 

in water, which neither digitalis nor digitoxin are, there is an obvi- 
ous advantage in its hypodermic use in such cases. 

Many physicians in France and America are using strophanthin. 
It is soluble in water, which digitalin is not. and is therefore better 
for hypodermatic use. The dose is from one-hundredth to one-flve- 
hundredth of a o T ain. In some cases digitalis and digitalin seem to 
contract the arterioles so much that the heart is made to work too 
hard to overcome this obstruction. Here strophanthus and stroph- 
anthin should be used, because it only slightly contracts the arteri- 
oles. The same can be said of coronilla. 

Dr. R. Babcock, of Chicago, uses convallaria. and its alkaloid 
convallaramirj. when digitalis does not agree with the patient, or has 
ceased to act after it has been used some time. The officinal dose 
of the active principle is put at one-hundredth of a grain (1c). which 
may do good service in neurotic affections of the heart : but in threat- 
ened failure from dilatation and incompetency, it requires from one- 
twentieth to one-tenth of a grain repeated every four hours. Dr. 
Babcock asserts he has saved life bv giving one-sixth of a 2Tain. 

Strychnine is a most valuable remedy in the treatment of the 
senile heart : it is a most admirable gastric tonic, especially when 
venous congestion and a tendency to catarrh exist, as is so constantly 
the case when the circulation is feeble : it improves the circulation 
by increasing the intra-arterial blood-pressure, and it stimulates the 
motor ganglia of the heart, accumulating energy (resp. excitability) 
within them. In a great many cases, even of well-marked senile 
irregularity, the continuous use of strychnine is sufficient of itself to 
promote a cure, while it is a powerful adjuvant to the use of digi- 
talis, and the combination of these two drugs often enables the most 
admirable results to be obtained, quite unattainable by either sepa- 
rately. As strychnine is the active principle of nux-vomica, similar 
results are occasionally obtained by employing either the extract or 
the tincture of that drug : but as the quantity of strychnine present 
in either of these preparations is uncertain, it is always better to em- 
ploy the liquor stryclininse hydrochloratis. as only thus can we secure 
an accurate dosage. Strychnine is said to be a cumulative poison, 
and so it doubtless is. but if a moderate vet effective dose is given. 
its use may be continued for many years without the slightest indi- 
cation of any poisonous action. I have known of five minims of the 



742 THE PRACTICE OF MEDICINE. 

liquor strychninae (one-twentieth of a grain of strychnine) to be taken 
continuously twice a day for over ten years, with nothing but a con- 
stantly increasing benefit ; while, on the other hand, I have seen so 
small an increase as another five minims — fifteen minims in the day — 
followed in no long time by indications of a poisonous action. In 
the use of all drugs idiosyncrasy occasionally turns up, and for this 
we must be prepared, but the doses I have indicated are those suit- 
able for by far the larger number of people. When we have to do 
with small, but especially with anaemic, patients, we must reduce the 
dose of all cumulative drugs to a minimum, and even then there may 
be intolerance in a few cases, and it may be needful to vary the drug. 
Thus, in cases in which we would by preference have employed dig- 
italis, or even a combination of digitalis with strychnine, we may be 
able only to use strychnine, and even that in almost infinitesimal 
doses. But these are very exceptional cases. The reverse by no 
means holds good ; it would never do to give a patient a larger dose 
than usual because he happens to be bulkier or more full-blooded 
than usual ; a larger dose may be tolerated, but it must be only 
rarely necessary, and we must feel our way towards it with consid- 
erable caution. 

In spite of the old dictum of our school, I have advised and used 
for many years a combination of digitalis and nux vomica, each tab- 
let containing two drops of the tincture of each ; also, a tablet of 
digitalis and strychnine, containing one-hundredth of a grain of each. 
I have never seen any but good results from them, and I have found 
that the combined is better than the alternated action. In anaemic 
patients I give a granule of iron, digitalis, and strychnine. All fears 
of antidotal action is absolutely baseless. Each drug does its own 
work, independently of the other. 

" Arsenic is another of those remedies indispensable in the treat- 
ment of the senile heart, quite as much so as digitalis. It is an ex- 
cellent tonic and stomachic ; it is one of the best anti-neuralgics we 
possess, and has been found extremely useful in many cases of an- 
gina ; it is said to increase the number of the blood corpuscles, and 
to restore youth and vitality to old worn-out horses and men. And 
it does all this often in the most minute dose ; one-hundredth of a 
grain of arsenious acid once a day is often the largest dose that can 
be tolerated. I well remember one old gentleman, who had been 



DISEASES OF THE HEART. 743 

taking one-hundredth of a grain of arsenious acid for two or three 
weeks, and nothing else, for a dilated and hypertrophied heart, say- 
ing to me : 'I don't know what benefit you expected from the treat- 
ment, but I know what I have received ; I can go up-stairs now much 
easier than I used to do.' Whereupon I expounded to him the use 
of arsenic by the Styrian mountaineers, for the purpose of improv- 
ing their wind and enabling them to climb their mountains more 
easily. Arsenic may be given alone, or it may be combined with 
digitalis or with strychnine and arsenic. 

" In cases where the blood is deficient in haemoglobin, iron is a 
positive necessity ; it should be given along with the food, and never 
at the same time as digitalis, this combination being extremely apt 
to sicken. (This is not the opinion of Fothergill, and I never found 
it to do so.) The proto-salts of iron are to be preferred to the per- 
salts, as they are more easily decomposed by the acids of the gastric 
juice, and are therefore more readily assimilated. Large doses in 
such cases are not as a rule required. Next to strengthening the 
heart and improving the blood, lowering the blood-pressure is the 
most important object of our treatment ; indeed, we cannot in many 
cases do anything towards strengthening the heart till we have low- 
ered the blood-pressure, the heart resenting and rebelling against all 
till the obstacle to the freedom of its action is removed. In all cases 
of angina, also, whether vaso-motoria or not, the initial stage would 
seem to be a sudden rise of blood-pressure, not always, perhaps, 
detectible in the pulse, but always perceptible to the heart, and to 
be relieved by promoting the free passage of the blood through the 
arterioles. For prompt and immediate relief to the pain of angina, or 
breathlessness due to vaso-motor and bronchial spasm that so accom- 
panies the senile heart, there are two drugs of supreme importance, 
nitrite of amyl and nitro-glycerine ; sometimes the amyl seems to 
give most relief, and at other times the nitro-glycerine ; of the two, 
the trinitrin (glonoin) has the most persistent action, and is, upon the 
whole, the more certain, and therefore to be preferred. Nitrite of 
amyl seems to lose its usefulness somewhat by keeping ; it still flushes 
the face and unlocks the arterioles, but does not relieve the pain. 
Several years ago I had a patient who suffered much from angina, 
and who only got relief from the amyl when freshly prepared. Since 
then the amyl has been introduced into hermetically sealed glass cap- 



744 THE PRACTICE OF MEDICINE. 

sules, and this seems greatly to preserve its efficacy. All the nitrites 
are available for relieving spasm and lowering blood-pressure ; but 
the nitro-glycerine seems to act most rapidly and effectively, and in 
the form of tabellae, each containing l-100th of a grain, it is easily 
carried about and readily available upon the slightest indication of 
pain or spasm. One or two of these give relief in about a minute, 
which lasts for one or more hours ; these tabellae may be repeated 
several times a day if required. The ill effects it may produce are 
headache, giddiness, throbbing of the cerebral arteries, and palpita- 
tion ; but it is somewhat remarkable how rarely these are complained 
of. Most patients prefer the nitro-glycerine to the amyl, and in the 
form of the liquor trinitrinae its action is even more rapid than as 
tabellae, but of course it is less easily carried about. When the high 
intra-arterial blood-pressure is more persistent and more distinctly 
gouty in its character, the iodide of potash is to be preferred, as, 
though less rapid, its action is more permanent. The iodide does 
not require to be given in larger doses than two or three grains every 
night or every twelve hours, but it ought to be persevered with for 
some time. Combined with twenty grains of bicarbonate of potash 
it forms one of the best remedies for the relief of high blood-pressure 
having a gouty origin. Where there is a tendency to cardiac failure, 
the addition of an appropriate dose of digitalis enables the heart to 
rally and restores its tone, a result which digitalis alone is unable to 
effect as in these circumstances it is apt, apart from the iodide, to 
produce cardiac irritation by goading the heart to useless exertion 
in the face of an obstacle it is unable to overcome. Larger doses of 
the iodide than two or three grains twice or three times a day are 
quite unnecessary and they may even do harm by destroying the 
albuminates in the blood, and so interfering with the nutrition of the 
heart, that organ being the most sensitive of all in regard to its meta- 
bolism. Throughout the literature of cardiac disease there are many 
cases recorded of extreme and distressing cardiac irregularity at once 
relieved by a fit of gout ; all of these would no doubt have been just 
as well and as speedily cured by the use of colchicum ; this is a mat- 
ter not to be lost sight of. A mild course of anti-arthritic medica- 
tion is often of the utmost service, and it may very readily be com- 
bined with other remedies, especially with digitalis. 

Where a thorough alkalizing of the contents of the primae viae 



DISEASES OF THE HEART. 745 

is desired, two or three bottles of Vichy water are very effectual, 
taken one small tumblerful before breakfast on first rising, and an- 
other about an hour before dinner. 

Flatulence is occasionally in itself a most distressing part of the 
ailments accompanying the senile heart, and even when it exists to 
but a limited extent it often distresses and alarms by its action on 
the heart, producing intermission, irregularity, or even severe attacks 
of tremor cordis. Even when a flatulent stomach does not give rise 
reflexly to these symptoms, it often produces them directly by pres- 
sure on the heart when the patient stoops, and this is perhaps as 
alarming an accident as could happen to anyone. In apparently 
perfect health he stoops to pick up a pencil or to tie his shoe, and 
his heart suddenly runs off in a fit of irregularity or of tremor. If 
there is any time in one's life when it is permissible to take a dram, 
surely this is one, and we have the authority of popular experience 
in its favor, for " there's naething like a wee drap speerits for con- 
gealed wind " — imprisoned flatulence. Accordingly, to those subject 
to these attacks I permit a small flask containing about a glass and 
a half of brandy or whisky for the day's consumption, in occasional 
sips as required, and not to be exceeded. Besides this, of course, 
the patient must be carefully dieted, and have with each meal some 
pepsin. I prefer one of the acid solutions of pepsin, which combines 
excellently with the liquor strychninse and arsenic, forming an ad- 
mirable tonic both to stomach and heart." 

Collinsonia is an excellent medicament for intestinal flatulence, 
affecting the heart ; so, also, is lycopodium, oleum cajuputi, and asa- 
fcedita, and terebinth has given relief in severe cases. 

" Such, then," says Balfour, in concluding his paper, " is the ar- 
mamentarium most useful in senile heart troubles. They are all 
valuable remedies in suitable cases, for though some of them are 
interchangeable, yet each has its own peculiar mission for which it 
is best adapted. Each case must be carefully considered from every 
point of view, thoroughly individualized, and the treatment best 
adapted to attain the end in view carefully and firmly laid down and 
persistently carried out. A disease which has been gradually com- 
ing on for thirty or forty years cannot be expected to be remedied 
in a week or two ; it often takes many months of care before irreg- 
ular hearts are made regular, or the declension of a failing heart is 



746 THE PRACTICE OF MEDICINE. 

arrested. With time, however, all this can be done ; time, however, 
is required, for it is not to be done by any dextrous legerdemain, 
but by the skillful imitation of natural processes and by the steady 
accumulation of trifling advantages, and our drugs must be mixed, 
like Opie's colors, 'with brains.' " 



PAIN IN THE HEART. 

" Very often," says Dr. Shrady in the " Medical Record," " pain 
experienced by those suffering from heart lesions is due to pleuritic 
trouble, to the rheumatic diathesis, or to some functional nervous dis- 
turbance. At the same time pain in the left half of the thorax always 
suggests a possibility that its relation to cardiac abnormity is more 
than coincidence. The "Lyon Medical," November 1, 1891, quot- 
ing from another journal, gives in substance Dr. Nothnagel's recent 
contribution upon this subject, based upon the study of 483 cases, 
all neuropathic, painful precordial affections and pericarditis being 
excluded. Cardialgia is of extreme frequence in aortic insufficiency 
and stenosis, and rare in mitral regurgitation. Leaving out schle- 
rosis associated with obliteration and stenosis of the coronary vessels, 
the author finds that in musculo-cardiac defects pain is frequent only 
in arterio-schlerosis with hypertrophy of the heart. The clinical 
aspect in this case is identical with symptomatic cardialgia associated 
with valvular disease. The pathogenesis of this pain is not discussed, 
our knowledge of the heart's nervous mechanism being as yet too 
circumscribed for the establishment of any theory. The extreme 
frequence of cardialgia in aortic affections seems to indicate that its 
origin lies in the artery itself. Diseases of the arteries are always 
extremely painful. This accords with the fact that in cardiopathies 
in general there are frequent lesions of the coronary vessels." 

But recent autopsies of persons dying from angina pectoris have 
shown that no abnormal condition appreciable to the eye existed in 
the coronary vessels. 

Writing again of " Heart Pain," the same writer in an editorial 



" The statement is often made to patients who complain of pain 
about the heart that it is due to the pressure of the stomach when dis- 



DISEASES OF THE HEART. Ill 

tended with food or gas. It is unquestionably true that many who 
think they have heart disease are in reality dyspeptics, but it is equally 
well known that many conditions produce painful sensations of vari- 
ous kinds in the heart itself, and when intercostal neuralgia, myal- 
gia, or muscular rheumatism of the chest-wall, cutaneous hyperal- 
gesia, and localized pleuritis have been eliminated, there still remains 
a considerable number of causes for pain in the heart region. 

"Nothnagel has recently made the attempt to show the causal rela- 
tion between cardiac pain and actual disease of the organ, and has 
tabulated nearly five hundred cases of valvular disease with this 
object in view, excluding neuroses with precordial pain as well as 
instances of pericarditis. The result of his study of the question, 
which is published in the "Zeitschrift fur Klin, Med.," shows car- 
dialgia to be frequent in cases of insufficiency and stenosis of the 
aortic orifice, while it is extremely rare in insufficiency of the mitral. 
Sixty per cent of regurgitation in the former were found to be accom- 
panied by pain, while only seven and a half of the latter cases had 
painful sensations. Hyperalgesia of the skin localized over the region 
of the heart, even in the absence of spontaneous pains, was observed 
in a number of subjects. Attention is also called to the frequency of 
pain in disease of heart muscle, without concomitant valvular impli- 
cation as in simple myocarditis, fatty heart, cardiac hypertrophy, 
etc.; but the cardialgia in these special cases has nothing especially 
characteristic about it, and is only frequent in instances of arterio- 
sclerosis with hypertrophy. The obscurity which involves the whole 
subject of the heart's nervous system prevents the author from enter- 
ing upon a discussion of the pathology of these various pains, but 
he regards them as of much importance in the diagnosis of obscure 
cases. 

" Dr. Liegeois has recently reported to the ' Societe de Therapeu- 
tique ' several observations on the effect of the tincture of piscidia 
erythrina in certain heart pains, and has been led by his own expe- 
rience with the drug to regard it as a good analgesic in the more or 
less permanent pains of vascular cardiopathies. The effect of the 
remedy is said to be more analgesic than hypnotic, and it produces 
no gastric disturbances. It is said that its active principle, piscidine, 
slows the heart's action and lowers the arterial pressure. It is very 
necessary to have a tincture prepared properly and not too long before- 



748 THE PRACTICE OF MEDICINE. 

hand, as it does not keep well. The formula which the writer espe- 
cially recommends is as follows : 

ly Tinct. piscidse erythrinae gm. 60. 

Tiuct. verat. virid., — . — . 

Ext. aconiti rad. ale aa. gm. 15. 

S.: Thirty drops morning and night. 

It is greatly to be hoped that piscidia may prove a more valuable 

remedy for the relief of pain about the heart than many others which 

have been recommended for this purpose. Some of these painful 

sensations are very distressing to the patient's mind as well as to his 

body, and are not usually relieved by the remedies which influence 

beneficially the action of the organ." 

It always has appeared singular to me that a physician could 
have the effrontery to combine such drugs as the above — all known 
to relieve heart-pain — and then boldly declare that one of them, and 
that one of doubtful value, to be the drug which was efficacious. 
Such testimony is of no value. 

Dr. Samuel C. Chew, of Baltimore, recently read a paper before 
the Association of American Physicians on " Different Forms of 
Cardiac Pain." He opened his paper with the remark that cardiac 
pains were due to several affections which differed from one another 
both in nature and pathology. They were situated apparently, or 
actually, in the heart. We had no proper term by which to desig- 
nate cardiac pain. The three divisions which he considered were true 
angina pectoris, which occurred in paroxysms, at first, at least, was 
accompanied by increased arterial tension, and was usually associated 
with aortic or coronary disease, or fatty degeneration of the heart. 
The pain was a peculiar one, being really something in addition to 
a pain, a feeling of impending death. Of two pathological condi- 
tions, coronary obstruction and fatty degeneration, we could only 
suspect their existence during life. Hence, the prognosis might be 
equally grave, whether an organic lesion of the heart was or was not 
recognized. Like in the other forms, it was difficult to determine 
the exact relation between the symptoms and the lesion. The imme- 
diate cause seemed neurotic. In this form he had obtained the great- 
est relief from the paroxysms by the nitrites, especially nitrite of 
amyl. Closely allied with this type was the cardiac pain associated 
with Bright's disease. Here the iodide of potassium in large doses 
might sometimes ultimately prove beneficial by lessening the arterial 



DISEASES OF THE HEART. 749 

sclerosis. Nitrite of amyl again might relieve the pain. The third 
form considered occurred in dilatation of the heart, and it was attrib- 
uted to stretching and pressure upon the nerves. One of the best 
tonics was arsenic. 

Dr. A. M. Starr, of New York, in the discussion of this paper, 
mentioned two other cases of cardiac pain, namely, that occurring 
in connection with paroxysmal tachycardia, and the other in what 
he had termed the vaso-motor type of neurasthenia. He also referred 
to Nothnagel's article showing that the statement usually made, that 
cardiac disease was unaccompanied by pain, was an error. 

Dr. Musser, of Philadelphia, insisted upon rest and careful atten- 
tion to diet. 

Dr. McPhedran had found nitro-glycerine preferable to nitrite of 
amyl, and said its effects were more lasting. 

Dr. Stockton had often found cardiac dilatation at autopsy in 
which there had been no history of cardiac pain. 

Dr. Chew thought that nitro-glycerine was useful for preventing 
attacks, but not for relieving them after they had come on. 

Dr. Stockton related a case in which large doses of nitro-gly- 
cerine (half grain) relieved the paroxysm, while nitrite of amyl 
failed. 

Patients are frightened by pain in the left side in the region of 
the heart, when they are indifferent to pain in the right side. 

Our school, which selects our medicines symptomaticaUy, is much 
more successful in relieving supposed cardiac pain. We have in 
arnica, cimicifuga, cactus, bryonia, rhus tox., spigelia, ranunculus, 
senega, and other drugs, excellent remedies for these pains. Phen- 
acetin will cure more cases of cardiac pain than any other drug. 
If the pain is a chronic neurosis no drug equals arsenic, long contin- 
ued, for weeks or months. 

ANGINA PECTOKIS. 

This affection is sometimes called steno-cardia and breast-pang. 
It is not an independent affection, but a symptom connected with 
several diseases of the heart and blood-vessels, especially with changes 
in the coronary arteries and sclerosis of the roots of the aorta. True 
angina is a rare disease. It is characterized by paroxysms of excru- 



750 THE PRACTICE OF MEDICINE. 

dating pain in the region of the heart extending into the arms and 
neck, and occurs almost exclusively in men of adult age. The real 
pathology is yet uncertain. In most cases there is present aortic 
insufficiency, increased arterial tension, hypertrophy of the heart, or 
arterio-sclerosis. The immediate causes of an attack are generally 
sudden exertion, or emotional excitement. The paroxysms often 
occur at night, but may appear in the daytime. I have seen two 
cases where it invariably occurred after smoking a strong cigar. 

Several theories have been advanced as to the nature of the affec- 
tion, namely: (1) Neuralgia of the cardiac nerves. (2) Heart 
cramp. (3) Extreme distension of the ventricular walls. (4) 
Sclerosis with narrowing of the coronary arteries. (5) Vaso-motor 
spasm of the coronary or the peripheral arteries. 

I believe it may be caused by each of the above conditions, and 
perhaps others not yet mentioned. 

Symptoms. — In true angina the patient is suddenly seized with 
an agonizing pain in the region of the heart, and a feeling of con- 
striction as if the heart was seized in a vise. Then pains radiate up 
the neck and down the arms — generally the left — and there may be 
numbness in the fingers or in the cardiac region. The face becomes 
cold, pallid, ashy gray, covered with a cold sweat which may extend 
all over the body. Actual dyspnoea is not usually present in true 
angina. The paroxysm may last several seconds or a minute or two, 
during which the patient feels as if death was impending. The 
patient may drop dead at the height of the attack, or pass away in 
syncope. The condition of the heart during the attack is variable. 
Strange to say its beats may be uniform and regular, and even the 
character of the pulse may be normal. After the attack the patient 
feels exhausted and suffers as after a severe fright. Eructations 
and passage of large quantities of clear watery urine are common. 
He may rally in an hour or two and feel quite like himself, or be 
confined to his bed for several days. The attacks may occur every 
few weeks, or not for years, and during the intervals the patient 
may feel quite well. 

It is sometimes difficult to diagnose true from false angina pec- 
toris. The subjective symptoms do not afford a trustworthy guide. 
We must rely upon an examination of the circulatory system. Even 
in mild forms of true angina signs of arterio-sclerosis are usually 



DISEASES OF THE HEART. 751 

present. If on auscultation the aortic second sound is clear, not 
ringing, the pulse tension is low. the peripheral arteries soft, and the 
pulse compressible, the case is not one of true angina. 

False ana'ina is a common affection in nervous women. It is gen- 
erally hysterical and the vaso-niotor symptoms clearly present. Hys- 
teria simulates true angina as it does many other severe disorders. 
Dr. Huchard has given us the following concise points of diagnoses 
between the true and false angina. 

" True Angina. Pseudo- Angina. 

Most common between the ages of forty At every age, even six years. 

and fifty years. 
Most common in men. Attacks brought Most common in women. Attacks spon- 

on by exertion. taneous. 

Attacks rarely periodical or nocturnal. Often periodical and nocturnal. 
Not associated with other symptoms. Associated with nervous symptoms. 

Vaso-motor form rare. Agonizing pain Vaso-motor form common. Pain less 

and sensation of compression by a severe; sensation of distension. 

vise. 
Pain of short duration. Attitude: si- Pain lasts one or two hours. 

lence, immobility. 
Lesions: sclerosis of coronary artery. Agitation and activity. 

Prognosis grave, often fatal. Neuralgia of nerves (?) and cardio- 

plexus. Never fatal. 
Arterial medication. Autineuralgic medications." 

The pain in the left side in the region of the apex of the heart 
from which nervous and hysterical women suffer is often so severe 
as to simulate true angina, but the location of the pain and the fact 
that the patient is capable of agitated movements during the par- 
oxysm shows the real nature of the paroxysm. 

Prognosis. — If the patient has arterio- sclerosis or aortic insuf- 
ficiency the prognosis is bad. for sooner or later death will occur in 
one of the paroxysms. Sometimes, however, with judicious treat- 
ment between and during the attacks a complete recovery may be 
obtained. Xeuralgic angina may prove fatal in delicate persons with 
weak heart. Pseudo-angina never kills although it may make life a 
burden. 

Treatment of the Paroxysm. — In true angina the duration of 
the attack is usually so brief that no medicine except amyl nitrite 
acts quickly enough to give relief. One to five drops of this vola- 
tile liquid, inhaled from a handkerchief or a vial, will give prompt 
relief. The subiects of this disease should carrv with them the 



752 THE PRACTICE OF MEDICINE. 

perles containing a few drops of amyl. These are crushed in the 
hand or in a handkerchief and rapidly inhaled. In one case under 
my care the patient absolutely refused to have anything come near 
his mouth, it " suffocated him." I injected three drops mixed with 
ten of water under the skin and the relief was almost instantaneous. 
Glonoine can be administered in the same manner and will act quicker 
than when given by the mouth. Chloroform does not act quickly 
enough to arrest a paroxysm of true angina, which rarely lasts longer 
than a fraction of a minute. In pseudo and hysterical angina in 
strong girls chloroform may be given, and often arrests the paroxysm 
quickly. 

Morphine is of no value in real heart-cramp, but is of value in 
pseudo-angina. I have met with several instances in women in 
which the pain was in the right side near the axillary line, but I am 
sure it was of the same nature as the pain in the left side from ova- 
rian irritation, yet it simulated angina very closely. Some of these 
cases yielded in a short time to cimicifuga ; others were so severe 
that hypodermic injection of one-eighth of a grain of morphine had 
to be used. 

In the various forms of angina, if the heart is weak I would not 
advise the use of phenacetin. In all other instances I value it 
highly as a safe and efficient remedy. In mild cases a grain every 
half -hour will suffice. In severe cases one or two doses of five grains 
rarely fails to relieve. It is unfortunate that this useful medicine 
cannot be given hypodermatically on account of its insolubility. 
(For further treatment consult article on arterio-sclerosis.) 

General Treatment. — In all forms of angina the patient should 
lead a quiet life, avoiding all mental excitement and sudden severe 
physical exertion. If arterio-sclerosis is present the diet and regi- 
men should be regulated (see article on arterio-sclerosis). There 
are a few medicines which appear to have an influence in arresting 
or retarding the progress of degeneration going on in the arteries. 
Dr. Huchard, of Paris, France, finds that the iodides have this power 
if their use is prolonged. He prescribes twenty grains three times 
a day for several years, omitting the medicines for ten days in each 
month. He cites the cases of two men both with arterio-sclerosis, 
ringing accentuated second sound, and attacks of true angina, who 
under its use remained practically free from attacks, one case for 



DISEASES OF THE HEART. 753 

nearly three and the other for fully four years. In one case of my 
own the patient was made nearly free from attacks by the use of ten 
grains of iodide of sodium thrice daily for two years. Not all patients 
are tolerant of the drug nor does it always bring about improvement. 
Osier says he has had several patients who were not at all improved 
by the iodides. Some patients may be intolerant of one iodide and 
tolerate another. Iodide of potassium acts best in persons of strong 
muscular development. If the muscles are weak, iodide of sodium 
acts better. The iodide of strontium acts well in patients with del- 
icate stomachs, and possesses the advantage of not causing acne. 

Aurum is an excellent remedy in arterio-sclerosis in which there 
is an element of vaso-motor constriction. The chloride of gold and 
sodium or the iodide of gold has in several cases given me good 
results. The dose is three to five grains of the 2x (1-1 00th to 1-3 0th 
of a grain) three times a day. It should be continued for many 
months, with intervals, especially if pathogenetic symptoms appear. 

Glonoine (nitro-glycerine) is not only a valuable palliative in 
angina, but is of great value during the interval. I refer to its 
physiological action. In doses of l-100th or l-50th of a grain it 
relaxes the arteries even in arterio-sclerosis. In doing this it relaxes 
the heart-muscle and prevents heart-cramp. The dose should be suf- 
ficient to give a soft large pulse, without causing disagreeable head- 
ache. In some patients this result can be obtained with l-200th of 
a grain every four or six hours. Others require one-fiftieth of a grain, 
and several cases are reported requiring and tolerating one-half of a 
grain. It can be given with other medicines and does not seem to 
antagonize them. If these medicines fail to cure or cannot be taken 
there are several possible remedies which should be tried according 
to the law of similia. 

The poison of lachesis, naja, the scorpion, latrodestus, and some 
other venomous reptiles, cause attacks similar to angina pectoris. 
The sting of apis and some other insects have also caused pain and 
constriction in the region of the heart. 

The provings of latrodestus give some very characteristic symp- 
toms. Dr. E. H. Linnell, of Norwich, Conn., reports the following 
case treated with it : 

" S. L. G., a man fifty years old, of bilious temperament, a den- 
tist by profession, had slight attacks of angina after severe exposure 



754 THE PRACTICE OF MEDICINE. 

and over-exertion during the 'blizzard' in March, 1888. He did 
not consider them of sufficient importance to consult a physician 
about them, but some months later, he had a suppurative prostatitis, 
which was followed by considerable prostration, and the attacks of 
angina became very severe. I never could get a satisfactory descrip- 
tion of the character of the pain, and I never saw him during a par- 
oxysm. The pain was brought on by exertion of any kind, and was 
especially frequent soon after dinner. The pain was sometimes felt 
in the left arm, but was usually confined to the cardiac region. I 
once or twice detected a slight aortic obstruction sound, but aside 
from this failed to find any evidence of organic disease. The usual 
remedies gave no relief, but latrodestus 3c. was of great benefit. 
Under its use the attacks gradually became less frequent and less 
severe. He has taken no medicine now for at least six months, and 
he tells me that although he occasionally has a little reminder of his 
former trouble, the attacks are so slight that he pays no attention to 
them. I have given the remedy in another similar case, with even 
more gratifying success. The attacks were very promptly arrested 
and have not returned, although nearly a year has elapsed." 

Cactus grandiflorus takes the front rank as a homeopathic rem- 
edy in angina pectoris. It may not influence well-developed scler- 
osis of the arteries, but is perfectly indicated in vaso-motor, neuralgic, 
and pseudo-angina. The characteristic symptoms are the constric- 
tion of the heart, " as if with an iron band," and a tenseness of the 
pulse with narrowing of the arteries. All the cacti which have been 
proven show this symptom in a greater or less degree. Anhalonium, 
probably the most poisonous of all, ought to be equal to cactus. The 
dose should not exceed the lx dilution (one-tenth of a drop) every 
four or six hours in the intervals ; during an attack every five min- 
utes. Arnica is indicated when the attack arises from sudden strain, 
as in lifting. If the patient will keep quiet for a few days arnica 
will prevent further attacks. 

Rhus tox. ought to be useful under the same circumstances. 

Coca and cocaine have produced symptoms similar to angina pec- 
toris. Several persons have died under its toxic effects, presenting 
such symptoms. Struggling for breath, with cold, clammy extrem- 
ities indicate its use. 



DISEASES OF THE HEART. 755 

A few drops of the tincture of coca every ten minutes, or the 2x 
trituration of cocaine, is the proper dose. 

Quebracho or its alkaloid aspidiospermine is indicated for the same 
symptoms, and in the same or somewhat larger doses. It is espe- 
cially useful when walking brings on the intense dyspnoea and con- 
striction of the whole thorax. 

The old school unanimously assert that all the cardiac tonics — 
digitalis, convallaria, adonis, nux vomica, strychnine, oleander, and 
others are not to be given in the treatment of angina pectoris. They 
declare rightly that they are dangerous. The reason lies in the fact 
which they are cognizant of, that all such medicines produce similar 
symptoms by causing vaso-motor constriction and violent contraction 
of the heart-muscle. 

Now if any of these cardiac medicines are indicated by the symp- 
toms they will be useful in all forms of angina pectoris except in 
advanced arterio-sclerosis. The dose should be small, never exceed- 
ing a drop of the lx dilution. Several other medicines have been 
recommended for angina, among them aconite, iodide of arsenic, asa- 
fcetida (hysterical), cimicifuga, cuprum, lilium, moschus, kalmia, 
spigelia, tobaccum, and veratrum album. Of these cimicifuga is 
useful in spurious angina from a reflex of uterine or ovarian disor- 
ders. Lilium ought to be of value in the same conditions, but I 
have serious doubts of the trustworthiness of its provings. 

The phosphide of iron, of magnesium and of potassium are recom- 
mended by Shiissler for angina pectoris, but there is nothing in their 
provings that warrants their use, and his so-called biological indi- 
cations are purely theoretical. No clinical verifications have yet 
appeared that would warrant their use in this disease. 

Some empirical remedies have been recommended. Dr. Henning 
says he gave cenothra biennis to an old man with angina ; " twenty 
drop doses gave him prompt relief." 

Piscidia (Jamaica dogwood). — Several reports of its successful 
use in angina have appeared. It is recommended as a substitute for 
glonoine. The dose is from ten to thirty drops. I doubt its value 
in true angina, but it may be of value in pseudo or hysterical cases. 
Belladonna, hyoscyamus, solanun, lobelia, or iberis may be useful in 
some instances. 



756 THE PRACTICE OF MEDICINE. 

THE HEART IN PNEUMONIA. 

In all acute pulmonary affections, the condition of the heart should 
be closely watched and studied, for it is a matter of the highest 
importance, and much of our success in the treatment of these dis- 
eases depends upon the condition of the heart. 

In the beginning of acute pneumonia, the heart may be sound 
and strong, but as the disease progresses, we soon observe symptoms 
of obstruction of the pulmonary circulation. Those who are familiar 
with the pathology of inflammation of the lungs are aware of the 
causes of this obstruction, and I need not enumerate them. 

If the heart has been previously diseased, with valvular lesions or 
their consequences, or if there is fatty degeneration, or thinning with 
dilatation, then the pulmonary obstruction affects the whole heart, 
and comes on much sooner than if the patient had a sound heart to 
begin with. 

This is the reason why pneumonia is so much more severe in per- 
sons who have heart lesions, or disorders characterized by weakness 
of the myocardium, and a neglect of this fact is the cause of much 
fatality which could be prevented. 

So soon as obstruction of the pulmonary circulation occurs in 
patients with a previously sound heart, the right heart is the side 
that suffers, for its labor is greatly increased. In proportion to its 
inability to overcome the obstruction, there will be an accumulation 
of blood in the venous system. ' Excess of blood in the veins implies 
deficiency in the arteries, and hence all acute pulmonary inflamma- 
tions are characterized by an unequal division of the blood between 
the venous circulation and the arterial. 

" This condition," writes Dr. A. H. Smith (" Amer. Jour. Med. 
Sciences"), "has extremely important consequences, especially in 
acute pulmonary affections. In these we study the pulse with the 
greatest solicitude to judge how the heart, as we say, is supporting the 
struggle. But the arterial pulse gives no indication of the immediate 
peril, for it is not the left heart that is bearing the brunt of the bat- 
tle. The pulse tells its story only at second hand. It may be small 
and weak, but it is chiefly because the left heart does not receive 
enough blood from the lungs to fill its chambers and to distend the 
arteries. 



DISEASES OF THE HEART. 757 

"The trouble is not in lack of propelling power so much as in 
deficiency of blood to be propelled. But if, instead of feeling the 
radial pulse, we could lay our finger upon the pulmonary artery 
we should obtain information vastly more to the point. We should 
then be able to appreciate the degree of pulmonary obstruction by the 
fulness of the vessel, and to rate the power of the right ventricle by 
the force of the arterial beat. And in the relation of these two fac- 
tors one to the other is involved the issue of the case. Increasing 
obstruction with decreasing right heart power means death ; decreas- 
ing obstruction with sustained right heart power gives promise of 
recovery. It is a question with which the left heart, and, therefore, 
the radial pulse, has almost nothing to do. For the peril is not from 
general exhaustion, as, for example, in fever, nor from failure of the 
heart as a whole, as in some cases of infection, but specifically from 
tiring out of the right heart in its effort to unload the venous circu- 
lation through the obstructed vessels of the lungs. 

" Now, while we cannot place our finger upon the pulmonary 
artery, we can obtain nearly the same information by applying the 
stethoscope over the pulmonary valve. Owing to anatomical condi- 
tions which it is not necessary to describe, it is entirely practicable 
to separate the pulmonary valve sounds from the aortic, and by means 
of auscultation to study the peculiarities of the former as indicating 
the conditions of the pulmonary circulation. Unfortunately, how- 
ever, in some cases the valve sounds are masked by bronchial rales, 
so that it may be impossible to appreciate them accurately. But 
even in the most rapid breathing there are brief intervals, during 
which the practiced ear may nearly always gather the required 
information. Xow, if we note carefully the sound of the pulmonary 
valve in, for example, a case of pneumonia, we shall find that at the 
outset, while the right ventricle is still in vigorous action, this sound 
is especially clear and sharp, indicating a quick and strong recoil of 
the pulmonary artery following the ventricular systole. This sharp 
recoil is due to unusual distension of the vessel, and this in turn is 
due to the resistance which the blood meets in passing through the 
lungs. If the case is to terminate favorably, this accentuation of the 
pulmonary sound will probably continue through the whole course 
of the disease, becoming less marked as the obstruction in the lung 
deceases. 



758 THE PRACTICE OF MEDICINE. 

" But in cases of increasing severity, and with an unfavorable ten- 
dency, a time soon comes when not only this accentuation is lost, 
but the normal intensity of the valve sound is lessened, the sound 
becoming weaker and weaker, until it ceases to be heard. This 
means, not that the obstruction has become less, but simply that the 
muscular power of the right ventricle has become exhausted with the 
labor exacted of it. The blood is no longer driven into the artery 
with sufficient force to distend it, and there is not enough recoil to 
bring the valve cusps together with an audible sound. When this 
point is reached, the end is not far off. The weakened right heart 
favors still greater pulmonary obstruction, and this in turn adds to 
the burden of the right ventricle, thus completing the vicious circle. 
The struggles of the ventricle become feebler and feebler, while the 
tension within its cavity constantly increases, as the blood presses 
into it from behind. At last there comes a moment when the over- 
taxed muscle cannot summon the energy for another contraction, and 
its action ceases in diastole. 

" The steps which lead up to this result are in a great degree trace- 
able by symptoms and by physical signs. First of all, there are aus- 
cultatory and other signs of pulmonary obstruction ; then come signs 
of general venous congestion. The distended right auricle may be 
traceable by percussion, or even may be seen pulsating at the right 
of the sternum. An increased area of cardiac dulness extending 
toward the xiphoid cartilage indicates the repletion of the right ven- 
tricle, and, in spare subjects the labored beating of this may be felt 
by pressing the finger under the costal cartilages. The tense hard 
pulse of inflammation is replaced by the small, creeping pulse of arte- 
rial depletion. The superficial veins are seen to be unusually prom- 
inent and the liver is enlarged. The spleen also is increased in size, 
and evidence of intestinal congestion may be afforded by copious diar- 
rhoea. Proof of passive hyperemia of the kidneys is found in les- 
sened excretion and albuminuria. Thus, all things combine to indi- 
cate a general preponderance of blood in the venous side of circula- 
tion, the result which we should naturally expect from a retardation 
of the blood in the pulmonary vessels." 

Dr. A. H. Smith, whom I have just quoted, discusses the method 
of treatment of this accumulation of blood in the venous system. 
" Manifestly," he says, " it is to diminish in every safe and proper 






DISEASES OF THE HEART. 759 

way the disparity between the venous and the arterial supply." He 
admits that the former method of venesection only resulted in tem- 
porary relief. Withdrawing a large amount of blood from the 
venous system would naturally give relief to the congested lungs 
and give a brief respite to the overworked right ventricle. He be- 
lieves that the beneficial effects of bleeding can be obtained by other 
and less objectionable means. He dwells upon the importance of 
regulating the quantity and quality of the diet in reference to the 
changed conditions of congestion and haeinatosis. He believes more 
food is usually given than is beneficial or necessary. An excess of 
food increases the venous congestion. It gives rise to flatulent dis- 
tension, rendering respiration more difficult, and there is also the 
risk of loading the blood with more nutritive material than the imper- 
fect respiration can act upon in the process of sanguinefication. I 
believe he is right, for I have observed that under a diet of beef-tea 
and albuminous foods the respiration became more oppressed, and 
the action of the heart more labored. I would suggest that those 
substances be banished from the dietary, until convalescence is fully 
established. Milk may be given, but not in large quantities. It 
should be mixed with half its bulk of Vichy, seltzer or some alkaline 
water, and well shaken before swallowed. If we have the slightest 
doubt of its purity, it should be sterilized. Pure soft water should 
be allowed ad, libitum. If diarrhoea is present, mix the milk with 
lime-water or rice-water. If there is constipation, with farina gruel. 
These foods are all-sufficient until the right heart has ceased to be 
overworked. Dr. Smith is in favor of the use of alcohol, which he 
declares is a food when given in a reasonable quantity ; not after 
the method once so much in vogue with English physicians, who 
often gave it to the verge of intoxication, but only enough to " relax 
the arterial system." In this respect, I believe he is right. It does 
not require more than a few fluid drachms a day to get this effect. 
But instead of using brandy, whisky, or the heavy wines, which are 
rarely pure, I prefer the purified alcohol. Of the above, good old 
whisky is doubtless the best. Nor would I give sweet wines ; the 
dry wines are far more readily assimilable. I prefer a good sauterne, 
and I can recall many cases of pneumonia in delicate women and 
children, to whom I allowed a pint daily of this wine, mixed with 
equal parts of pure water or Vichy, with the happiest results. In 



760 THE PRACTICE OF MEDICINE. 

children and delicate women, wine- whey, made with sauterne or hock, 
acts admirably. When the nervous system is greatly depressed and 
there is delirium, with trembling, we can use alcohol liberally, with 
the greatest benefit. 

But there are some of the newer medicines which act similarly to 
alcohol on the vaso-motor system, and I have used them for years 
when I desired to get rapid relaxation of the arterial system. I refer 
to amyl nitrite, nitroglycerine (glonoine), and the nitrites of sodium 
and potassium. When any of these drugs are given in minute doses, 
by their specific effects, either upon the vaso-motor system, or directly 
upon the muscular fibres of the arteries, they cause a relaxation, and 
consequent dilatation of the whole arterial system. This gives great 
relief to the over-distended venous system. 

In conditions of sudden collapse from over-distension of the right 
heart, I am certain I have saved the patient's life by a few inhala- 
tions of amyl, or a hypodermatic injection of glonoine, one-fiftieth of 
a drop. 

The effect is startling. The blue and cold lips, face, and hands 
in less than a minute become suffused with red blood, and the flut- 
tering or absent pulse becomes full and strong. The effects of these 
two agents are evanescent, and we must repeat them often. Amyl 
should be used only in cases of great emergency, and should be fol- 
lowed in a few minutes by glonoine, whose effects last an hour or 
two. The action of the nitrites of soda, potash, and ammonia last 
longer, for hours, and can be given in doses ranging from one-tenth 
to one grain. Probably the nitrite of ammonia is the best, for it 
remains stable in an aqueous or dilute alcoholic solution in which 
there is one per cent of free ammonia. The one per cent solution, 
in doses of ten drops up to one drachm, can be given with signal 
advantage. 

But there are other drugs, which have long had a deserved popu- 
larity in pneumonia, which act in a matter similar to the nitrites. 
Aconite and veratrum viride are the most potent of these. But they 
do not act alike. Aconite is indicated when the action of the heart 
is rapid and its contractions short, sharp, and labored. Veratrum, 
when the heart beats powerfully, with heavy, bounding impulse. Aco- 
nite is indicated when the pulse is quick, hard, and small, the artery 
vibrating like steel wire under the pressure of the finger. Veratrum, 



DISEASES OF THE HEART. 761 

when the pulse is large, hard, and vibrating, denoting violent, forci- 
ble impulse of the heart against a powerful vaso-motor spasm of the 
arteries. 

I am sure that in the hands of those who know how to use these 
powerful drugs, pneumonia has been averted in its first stages. I 
believe I have used them with that result many times, but I do not 
believe the attenuations can be used with such results. However 
successfully they may be used in ephemeral and catarrhal fevers, 
when given in attenuated doses they are useless in the onset of pneu- 
monia. Tessier did not shorten the average duration of a single case 
under the administration of the 15th dilution of aconite. The cura- 
tive dose in acute pneumonia lies in the first decimal dilution, in one 
to ten drop doses, of either drug, repeated every hour or two. There 
is not the slightest danger, even in children, from the use of these 
doses. I once gave veratrum viride to a child of two years with acute 
lobar pneumonia, with the characteristic pulse, and a temperature of 
104° F., in doses of one drop of the tincture every hour, with the 
result of bringing the pulse to normal (96), and the temperature to 
99° in twelve hours. Phosphorus and tartar emetic completed the 
cure in five days. 

There is another effect belonging to the action of aconite and vera- 
trum viride, which is of great value in pulmonary inflammations. 
Their sedative effect on the heart itself is undoubted. When the 
proper dose is given, the heart's pulsations are always rendered 
slower and weaker. Here I will call attention to the antagonistic 
properties of aconite and veratrum, as compared with digitalis and 
ergot. The latter contract the arterioles, slow the action of the heart, 
but increase its force. If we were obliged to select drugs which are 
primarily homeopathic to the stage of obstruction and venous stasis 
in pneumonia, we should select digitalis and ergot, and use them 
in the high attenuations ; but I am not aware that this has ever been 
done, nor do I believe the result would be to remove the obstruction. 

There are some facts which seem to prove that the secondary 
effects of aconite and veratrum would be to cause a condition of the 
heart and arteries simulating obstruction, but I prefer to believe that 
their action in dilating the arteries and in decreasing the force of the 
heart to be purely physiological. I believe that by this action, when 
carried only far enough to relax the arterioles, decrease the force of 



762 THE PRACTICE OF MEDICINE. 

the heart and lower the temperature, we are able to prevent the 
obstructive state. 

But suppose we are not able to do this, and we find the patient 
presenting the signs and symptoms of obstruction mentioned by 
Dr. Smith ? Then, we should not give aconite or veratrum, but 
resort to medicines which will dilate the arterioles, and allow the 
arterial blood to pour into them, taking off the excess of blood in the 
right heart. 

In this stage we must rely, in addition, on those medicines which 
are homeopathic to the inflammatory process going on in the lungs. 
Phosphorus, tartar emetic, and sanguinaria are a powerful trio in 
such cases, when given according to the indications so well known 
to our school. 

Phosphorus is of the greatest importance when the right heart 
is almost paralyzed and collapse threatens. Given in alternation 
with glonoine, its power is heroic in saving the patient from disso- 
lution. 

The question as to the use of digitalis and its analogues, strophan- 
tus and strychnine, in the stage of pneumonia with threatened heart- 
failure, is open to discussion. Dr. A. H. Smith advises against their 
use, which he declares to be unsafe. They act chiefly on the left side 
of the heart, which is not the side which fails. Bristowe mentions 
that in many cases of death in pneumonia the left ventricle was found 
firmly contracted, while the right was distended by a clot which ex- 
tended into the pulmonary artery. 

Why are not the arseniate and the iodide of antimony more used 
in acute and chronic pulmonary troubles ? In the obstructive stage, 
when the respiration is labored and the left heart is weak, with coarse 
rales and inability to expectorate, the arseniate is admirably indi- 
cated. In the stage of gray hepatization, when the bronchi are 
filled and obstructed and the dyspnoea great, the iodide should be 
used. 

Chloroform has a close analogy to the glonoine and the nitrites. 
The " sweet spirits of nitre " is a nitrous ether, and acts like a nitrite. 
Hahnemann recommended this preparation in about the same con- 
dition for which we use glonoine. I have always got the best results 
from phosphorus in pneumonia and typhoid fever when the tincture 



DISEASES OF THE HEART. 763 

was prepared with chloroform. In pneumonia, in the obstructive 
stage, give the 3d dil. in chloroform, two to five drops in a spoonful 
of water, and you will be pleased with the effect. 

Sanguinaria is a rival of tartar emetic in the severest cases of 
pneumonia, and in chronic cases no remedy equals it. Chelidonium 
is a near botanical relative, and it contains some of the constituents 
of sanguinaria. Moreover, there is a close similarity in their symp- 
toms. 

Certainly in the condition described by Dr. Smith, quoted above, 
digitalis could not safely be given. Yet many physicians of both 
schools assert that when the heart flags and the pulse becomes weak 
and irregular, they use digitalis with decided benefit. Many of late 
praise strophanthus highly in similar conditions, especially in the 
inflammatory affections of the lungs in children. Others praise 
strychnine when paralysis of respiration threatens, and the breathing 
becomes shallow and labored. There must be conditions in pneu- 
monia when the typical obstructive stage does not obtain ; conditions 
where the whole heart becomes weak and failure of both sides is 
impending. I know that I have had good results from all three 
drugs in many cases, and I would not like to give up their use. 

Probably we shall be able to select those cases where the nitrites, 
glonoine, amyl, and chloroform should be given by the indications 
laid down by Smith. I refer to the condition of the pulmonary 
valve, as shown by the stethoscope, namely : when the normal inten- 
sity of the pulmonary valve sound becomes weak or imperceptible. 
If we do not find this indication, but find the pulse feeble, irregular, 
or intermittent, the surface of the body cool, the extremities cold and 
damp, and the general heart-sounds feeble, then we may safely give 
digitalis or strophanthus, with phosphorus or arsenic, or arseniate of 
antimony. In addition to their cough, chest, and febrile symptoms, 
the state of the heart is often a guide to their administration. 

Sanguinaria is indicated when the heart's action is low and labored, 
the pulse slow and full, and generally irregular ; or in severe cases 
when the pulse is slow, small, and feeble. 

Chelidonium is indicated when the heart's action is labored and 
its action is felt through the clothing. If jaundice sets in the pulse 
becomes slower, and possibly feeble. 



764 THE PRACTICE OF MEDICINE. 

Phosphorus has a small, feeble, and irregular pulse, like one in 
collapse. Tartar emetic has about the same indications. Both are 
useful when the right heart is overtaxed. 

Turpentine has many points of resemblance to phosphorus. In 
cases of poisoning by both, the pathological conditions of all the 
important organs are similar. Tympanites and diarrhoea are arrested 
by both, but I prefer turpentine for these symptoms. When given 
by the mouth, or by enema, or applied to the abdomen, it generally 
gives quick relief. In many cases of collapse in pneumonia, when 
the respiration and heart's action seem on the point of failing, large 
doses of turpentine have had an undoubted effect in stimulating both 
to renewed functional activity. Especially in children does this rem- 
edy act well ; they are often killed by the mechanical result of a 
tympanitic abdomen pressing up the diaphragm and arresting the 
action of the overtaxed heart. 

Recently Dr. J. West Roosevelt read a paper before the Prac- 
titioners' Society of New York on " The Use of Heart Stimulants," 
particularly strychnine, in the treatment of acute lobar pneumonia. 
He said : 

" That death in a large number of cases of acute lobar pneumo- 
nia is directly caused by the exhaustion of the heart which the dis- 
ease-process produces is generally admitted. It is well known that 
patients suffering from this malady are very prone to syncope upon 
slight exertion ; indeed, a number of cases are on record in which 
sudden death has followed the effort to sit up in bed for the purpose 
of facilitating the physical examination of the chest. In a consid- 
erable number of cases death takes place very suddenly, as it some- 
times does in pleurisy with effusion, from syncope not caused by 
muscular exertion. In still others oedema of the lungs precedes the 
fatal issue. In all these cases it is the heart failure which kills. 
With the causes of this failure we have but little to do in the present 
paper. It is my desire to speak only of certain clinical phenomena, 
not to discuss theories. 

" Acute lobar pneumonia is a self-limited disease, which usually 
terminates by crisis within ten days. In very many cases, sooner or 
later the heart becomes weak, and in fatal cases death often results 
from heart failure. Sometimes the heart weakness is manifest at 
the beginning of the disorder, but more often it only becomes evi- 



DISEASES OF THE HEART. 765 

dent after the illess has lasted several days. It is very apt to be 
pronounced about the time the crisis is generally to be expected, and 
death is very common at this time (£. e., between the sixth and tenth 
days). The disease is of short duration ; if the heart can be forced 
to act for a few days recovery may be expected, and there is reason 
to believe that judicious treatment with cardiac stimulants can save 
many lives. The principal stimulants commonly used in pneumonia 
are alcohol in some form, digitalis, convallaria, and strophanthus, 
either singly or in combination, caffeine, ammonium carbonate, some 
of the nitrites, opium, musk, or nux vomica. There are, of course, 
a number of other heart stimulants ; but the ones mentioned are the 
most important. 

" The Indications for Stimulation. — There is, it seems to me, a 
good deal of difference of opinion as to the indications for exhibiting 
stimulants. On the whole, are we not apt to use them before the 
patient's condition demands them ? (It will be understood that I 
speak of the drugs named only as they are employed for the purpose 
of " stimulation " in the clinical meaning of the word.) There is an 
idea which has been often set forth, and which is often applied to-day, 
that it is right to stimulate in all cases where there is reason to ex- 
pect weakness of the heart to result from some acute disease long 
before such weakness becomes manifest. Syllogistically expressed 
in regard to pneumonia, it is : " Heart- weakness may be expected to 
result from the disease within from twenty-four hours to ten days ; 
therefore, let us forestall it by immediately giving stimulants, regard- 
less of the present condition of the heart." This is the actual prac- 
tice of many. It would be as rational to say to an athlete, "You are 
to be submitted to a severe strain in a short time ; you had better 
take a good deal of liquor." The athlete knows that to take stimu- 
lants in order to prepare for some strain upon his muscles which is 
not imminent, is folly. The heart is a muscle, and to stimulate it 
needlessly is to exhaust it. The need for stimulation is determined 
by the actually existing condition of the circulatory system, not by 
some condition which may obtain in the future. If a patient with 
pneumonia has a good pulse and shows no evidence of imperfect cir- 
culation, it is worse than folly to stimulate. 

" Concerning some of the Cardiac Stimulants. — Alcohol adminis- 
tered in wine, liquor, or some other solution, is of the greatest value. 



766 THE PRACTICE OF MEDICINE. 

It is needless to say more about it than has already been said, viz : 
that it is not well to give it without definite reason. In regard to 
digitalis, strophanthus, and convallaria, I can only say that I have 
never seen a single case of pneumonia in which benefit seemed to re- 
sult from their use. This may be because of my limited experience, 
but it is a fact. Opium and morphine have both seemed to be of 
distinct value as stimulants in a number of my cases. Passing over 
the other drugs, I wish to call attention to strychnine as a cardiac 
stimulant. 

" Strychnine has been in use for this purpose for a long time ; I 
have not been able to learn who first recommended it. Its value 
does not seem to have been appreciated by the majority of the pro- 
fession. While I do not pretend that it is capable of producing 
marvellous effects, I think it has a value which should not be over- 
looked. Especially is this so in patients in whom alcohol is power- 
less, as in old drunkards. It has seemed to me to increase the heart's 
strength in a remarkable way in a number of such cases. It has also 
seemed a most valuable drug when given in addition to alcohol in 
suitable cases, since it appears to increase the stimulating effects of 
the latter. 

" Administration and Dose of Strychnine. — It must be given in 
large doses. By far the safest mode of administration is the hypoder- 
mic. Given in this way each dose exerts its influence promptly, and 
there is no tendency to cause the so-called " cumulative action." 
From one-thirtieth to one-twentieth grain may be given at a time, 
and the same or a smaller dose repeated every half-hour, if neces- 
sary, until the heart becomes stronger or toxic symptoms begin to 
appear. The limit of safety may be assumed to have been reached 
as soon as a distinct exaggeration of the deep reflexes appears. The 
way I have adopted for demonstrating such an exaggeration is very 
simple. It is to lift the patient's forearm, the hand being allowed 
to hang with the extensors relaxed, and to strike the tendon of the 
supinator longus. If a marked contraction of this muscle occur, it 
is fair to assume that the reflexes are exaggerated. Strychnine is 
what might be called an honest drug, for it gives warning of toxic 
symptoms long before the latter appear, provided it is used hypo- 
dermically. 

" I repeat that I do not wish to claim for it more than a limited 



DISEASES OF THE HEART. 767 

range of utility, though I think that it may prove as valuable as alco- 
hol for heart stimulation." 

In the discussion which followed this paper Dr. Beverley Robin- 
son expressed some surprise that strychnine could be given in such 
large doses without producing toxic phenomena, for in some patients 
much smaller doses had seemed to do harm by interfering with sleep 
and causing irritability. 

Dr. George L. Peabody thought the author's experience very val- 
uable, and that it ought to be tested by others. He fully agreed with 
him with regard to the impropriety of giving stimulants, especially 
alcohol, to a patient because his heart might become enfeebled, but 
was not yet so. He could not believe that such was a general prac- 
tice, unless by medical tyros. He had frequently to curtail the 
amount of alcoholic stimulants prescribed by the house staff in 
hospitals. 

Dr. Andrew H. Smith had been much surprised at the amount 
of strychnine which Dr. Roosevelt had been able to give. Such ex- 
perience illustrated the fact that many powerful drugs could be given 
in much larger doses than had been supposed. For example, who 
without experience would not be startled at the amount of arsenic 
given by Dr. Osier, especially in pernicious anaemia: half a drachm 
of Fowler's solution three times a day. In giving alkaloids it should 
be borne in mind that they did not, as far as he knew, add anything 
to the nutrition of the heart-fibre. Their action was simply that of 
applying the whip, which might be useful in carrying the patient 
over a critical period, as it would be in urging a horse over a weak 
bridge before it could collapse. If the stimulants were used long, 
forcing the heart into unnatural activity, it was at the expense of 
molecular action and loss of strength, and was liable to bring on 
bankruptcy. Digitalis has never given much satisfaction in pneu- 
monia except when the heart was becoming intermittent, when it 
might restore the rhythm. There was a distinction to be made be- 
tween failure of the heart as a whole and failure of the right side of 
the heart. Right-heart failure, as distinguished from heart failure, 
was liable to take place when there was much obstruction to the cir- 
culation in the lungs, and ought to be managed differently from the 
cases in which the primary danger was to the heart as a whole. For 
instance, raising the patient with pneumonia, in bed, incurred risk 



768 THE PRACTICE OF MEDICINE. 

to the entire heart, because of its participation with the rest of the 
muscle in the general weakness induced by the disease. That was 
very different from the inefficiency of the right heart due to sluggish- 
ness of the pulmonary circulation. 

Dr. F. P. Kinnicutt said he had given very large doses of strych- 
nine hypodermically in pneumonia, with very satisfactory results. 
He had not, however, carried it up to one-thirtieth of a grain. It 
compelled to rely upon only one drug as a cardiac stimulant in pneu- 
monia, he would choose strychnine. 

I agree, in the main, with the views of the above physicians. The 
remedies they recommend are physiological tonics, but they act hom- 
eopathically by their similar secondary action. In some cases we 
will find veratrum album and veratrum viride, aconite, and cactus, 
equally valuable, acting homeopathically by virtue of their primary 
action. 



ARTERIAL TENSION. 

The following concerning high and low arterial tension is made 
up from the writings of Broadbent and others whom I have men- 
tioned further on. I have followed Broadbent, who is the highest 
living authority. 

HIGH ARTERIAL TENSION. 

Unduly high pressure in the arterial system or high tension of 
the pulse is a condition worthy of careful study and attention. It 
explains many of the forms of failing health at and after middle age, 
and is often the means of shortening life through lesions of the brain 
and heart. It points out tendencies which later result in serious ill- 
ness or fatal disease, and its recognition often directs us to measures 
by which ailments may be relieved, and enables us to foresee and 
sometimes to avert premature death. 

Characteristic of High Tension Pulse. — High arterial tension 
is not to be measured by a certain number of grammes or ounces of 
pressure employed to elicit a characteristic sphygmographic trace; 
it is a relative, not an absolute, term. Ultimately, the measure of 
the tension in the arteries is the force of the systole or the heart, but 
modifying influences of extreme importance are introduced by the 



DISEASES OF THE HEART. 769 

peripheral circulation. Under normal conditions the relation be- 
tween the force of the heart and the outflow by the capillaries is 
such that the artery gradually subsides under the pressure of the 
fingers in the intervals between the pulse-waves ; and the chief char- 
acteristic of unduly high tension is that the vessel remains full be- 
tween the beats. For our present purpose, then, it may be taken 
that high tension exists whenever the artery is full between the beats, 
so that it can be rolled under the fingers like a tendon in the wrist. 
To appreciate this condition, three fingers should be placed on the 
vessel, when it will be found to stand out not only during the wave 
of the pulse, but in the intervals ; and, as has just been said, it can 
be rolled transversely under the fingers, and can often be followed 
for some distance up the fore-arm. 

The force of the pulse-beat and the degree of actual pressure in 
the blood column may vary. This will be approximately estimated 
by the pressure of the fingers required to flatten the artery and arrest 
the wave, one, two, and all three fingers being employed, and the 
pressure being varied several times. Very frequently the force 
needed is unexpectedly great and a pulse which at first seems to be 
weak may really be extremely powerful. Not unfrequently, espe- 
cially when the skin is thin, the artery can be seen to form a dis- 
tinct cord-like projection along the line of its course, but no pulsa- 
tion will be visible in it, unless it is thrown into a curve, when this 
will be seen to be accentuated at each beat. The artery may be either 
large or small ; sometimes it is distended and dilated to its full ca- 
pacity, but so long as its coats are sound and not worn out, it will 
usually be contracted and small. The pulsation is not very marked, 
and to the fingers lightly applied seems weak, since, as has already 
been stated, when the mean blood pressure is high, the fluctuations 
are comparatively small. The onset of the wave is gradual ; it is 
felt for an appreciable and relatively long period under the fingers, 
and it subsides slowly. 

While there is no apparent vehemence of the beat, when the 
strength of the pulsations comes to be tested by an attempt to arrest 
the wave it is found to have an unexpected degree of force, and very 
often the greater the pressure of the fingers the stronger it seems to 
become. This is especially the case when the artery is much con- 
tracted and the pulse therefore small, the pulse under these condi- 



770 THE PRACTICE OF MEDICINE. 

tions often being supposed to be weak from the inconspicuous char- 
acter of the pulsatile movement. 

Virtual Tension, — An important deviation from the form of 
pulse just described may, however, be met with when the essential 
cause of high arterial tension obstruction in the peripheral circula- 
tion exists. This is usually at a late stage in the history of the case, 
when the arteries are worn out and dilated by old standing high press- 
ure of the blood within them ; when, also, the heart has yielded to 
the resistance by which it has opposed and dilation of the left ven- 
tricle has taken place. The artery then is large and full between the 
beats, but when moderate pressure is employed it allows itself to be 
flattened, and the pulse is sudden in onset and as sudden in its end- 
ing, the pressure in the vessel is abruptly raised, remains high for 
a brief period, and then falls abruptly. The ventricle, in fact, cannot 
go through with its systole in the face of the resistance in front. 
This may be called the pulse of virtual as distinguished from actual 
tension ; the peripheral condition for the production of tension exists, 
but the sustained central force required for " actual " tension is 
wanting. 

Causes of High Arterial Tension. — The causes of high arterial 
tension are many and various, namely: 

Increase in the Volume of Blood. — A constant repletion of the 
entire vascular system is present in the condition called plethora. 
This, of itself, would give rise to high pressure in the arteries ; but 
in plethora elimination is rarely efficient, and the blood is charged 
with waste products, which provoke resistance in the capillaries, so 
that an additional cause of arterial tension is present. Another 
instance in which an increase in the volume of the blood contributes 
lio the production of high tension is afforded by the early stage of 
acute desquamative nephritis, where the retained urinary waters at 
the same time dilutes the blood and augments its volume. 

Frequent and Powerful Action of the Heart. — This occurs in 
excitement and on exertion ; but high tension produced in this way 
is usually fugitive. The increase of pressure may, however, last long 
enough to do mischief. 

Arteriole Contraction. — The most simple example of this is the 
increased arterial tension which is produced by external cold. But, 
although a normal process, the increase of intra-arterial pressure is 



DISEASES OF THE HEART. Ill 

often the exciting cause of cerebral hemorrhage when predisposition 
exists in atheroma of the cerebral arteries. Every winter the first 
spell of cold weather is attended with a number of cases of apoplexy, 
as is each succeeding one. The cramp which proves fatal to swim- 
mers is almost certainly a general arterial spasm provoked by the 
chill of immersion, the resistance to the circulation being aided by 
the pressure of the water, while the heart is usually also weakened 
by exertion. It is not only after prolonged exertion in swimming 
that the so-called cramp occurs. I have known one instance in which 
a vigorous young man plunged into a pool and was seen by his com- 
panion to go straight to the bottom and lie there dead. One of the 
factors in the causation of angina pectoris, or, at any rate, in one 
form of this affection, appears to be general arteriole spasm. The 
prominent phenomenon of rigor is general arterial spasm ; and in the 
cold stage of malarial fevers this may be carried to such a degree as 
to bring the heart to a standstill by the resistance produced. It is 
from this cause that the cold stage of malignant intermittent or remit- 
tent fevers is attended with danger of fatal syncope or serious ner- 
vous complications. 

Cases are sometimes met with, independently of malarial poison- 
ing, in which general arterial spasm becomes a source of danger, as 
in some forms of angina pectoris. 

In hysteria, arteriole spasm is a highly characteristic feature, 
especially during a hysterical fit. The copious, limpid, watery urine 
is, no doubt, an effect of the high arterial tension so induced. Ner- 
vous excitement of certain kinds is attended with contraction of the 
arteries ; and this is the explanation of the diuresis of nervousness. 
In migraine, again, there is general arteriole spasm, and the attack 
itself has been attributed to contraction of the cerebral arteries. The 
early stage of meningitis is attended with arterial tension from con- 
traction of the arterial walls. 

Resistance in the Capillaries. — This is the most frequent and 
important of the causes of arterial tension. That certain substances, 
present in the blood in very minute proportions, give rise to obstruc- 
tion in the capillaries is clearly demonstrated by Drs. Ringer's and 
Saintsbury's experiments with digitalin, ergotin, etc., which show 
also that the effect is independent of reflex nervous influence, since 
it occurs when all the nerves are divided. The special material 



772 THE PRACTICE OF MEDICINE. 

which plays this part is almost certainly nitrogenized waste which 
has not undergone the complete oxidation necessary for elimination. 
The diseases, gout and renal disease, in which high arterial tension 
is most marked, are exactly those in which there is the greatest cer- 
tainty of the existence in the blood of the products of imperfect met- 
abolism. High arterial tension produced by arterio-capillary obstruc- 
tion occurs under the following conditions : 

(1) Age. — There is a tendency to the development of resistance 
in the peripheral circulation and of arterial tension with advanc- 
ing years ; it is one of the ways in which the tissues show that they 
are growing old. This is most marked when high tension exists 
from other causes. 

(2) Heredity. — Inherited tendency must in many cases be as- 
sumed as the only explanation of undue tension in the arterial sys- 
tem. No condition, indeed, runs more strongly in families than high 
arterial tension, and it is the explanation of a family liability to 
apoplexy and paralysis, or to death from heart disease. 

(3) Renal Disease. — Renal disease of whatever kind, except 
acute suppurative pyelitis and nephritis, and perhaps tuberculosis 
and amyloid degeneration, is attended with high arterial tension, due 
to the imperfect elimination of urinary constituents. 

(4) Gout. — Gout, again, is so constantly accompanied by high 
pulse tension that the term " gouty pulse " has passed into currency. 

(5) Diabetes. — In connection with gout may be mentioned dia- 
betes, one form of which is accompanied by high pulse tension and 
is closely associated with gout. 

(6) Lead Poisoning. — Lead-poisoning is another cause of high 
arterial tension. 

(7) Pregnancy. — Pregnancy is invariably accompanied by in- 
crease of tension in the arteries. Whether this arises from a gen- 
eral augmentation of the volume of the blood or from the presence 
in the blood of effete matters derived from the foetus, is perhaps not 
altogether settled. 

(8) Ancemia. — It is not easy to understand how anaemia can 
give rise to high tension in the pulse. One would have expected the 
watery blood to pass readily through the capillaries and the vis a 
tergo supplied by the heart to be deficient ; but it is a matter of 
daily observation that the artery is full between the beats, and that 



DISEASES OF THE HEART. in 

the pulse, if more abrupt than in renal disease, is long. The occur- 
rence of dilatation of the left ventricle and mitral regurgitation, 
which is very common as an effect of anaemia, is at once understood 
when the resistance in the peripheral circulation is taken into account ; 
it is not merely the innutrition of the walls of the heart, due to anae- 
mia, which causes them to give way, but the increased work thrown 
upon the left ventricle by this resistance. 

(9) Emphysema. — In cases of emphysema and chronic bron- 
chitis, and sometimes even in phthisis, the systemic arteries present 
the signs of increased tension ; in emphysema they are specially 
marked. 

The etiology of high arterial tension will require very few words. 
The remote causes are just those which conduce to the imperfect 
oxidation and elimination of nitrogenized waste. 

(1) Food. — A high proportion of animal food, and especially 
of butchers' meat, stands first on the list. There is no such great 
difference between fowls of all kinds or game and red meat as is 
popularly supposed, but perhaps meats contain more extractive mat- 
ters. Soups, beef-tea, and animal juices, meat extracts, and the 
like, however valuable, contain a maximum of potential waste in 
comparison with matters available for tissue nutrition. 

(2) Alcoholic Drinks. — Any form of alcoholic fluid in excess, 
spirits, wine, or beer, will interfere with the normal metabolic pro- 
cesses and lead to the retention of impurities within the system. 

(3) Sedentary Habits. — Inadequate amount of exercise in the 
open air, especially when a great part of the day is passed in offices 
lighted by gas and imperfectly ventilated, intensifies greatly the 
effects of excessive food and alcoholic drink, and will of itself con- 
duce to imperfect oxidation. 

(4) Constipation. — This is a very important cause of high arte- 
rial tension, and it acts in at least two ways. The undue retention 
of faecal matters in the large intestine leads to resorption of the 
fluid parts, and these constitute impurities in the blood likely of 
themselves to provoke resistance in the capillaries and calculated 
also to interfere with digestion and with metabolism in the liver and 
tissues generally, which would add to the impurities. The foul 
tongue and offensive breath, and sallow complexion attending habit- 
ual constipation are sufficiently suggestive. But constipation has a 



774 THE PRACTICE OF MEDICINE. 

direct influence on arterial tension, probably through the effect on 
the abdominal veins. This is patent to every-day observation if the 
pulse is examined before and after defecation. Many weakly per- 
sons are greatly depressed after even an ordinary evacuation, and 
come to dread it, and syncope is not uncommon after an unusually 
large motion. It is easily understood, then, how constipation becomes 
a source of danger and injury. It promotes high arterial tension 
both directly and indirectly, and a further danger arises from strain- 
ing at stool, which not infrequently determines the rupture of a 
cerebral vessel, or breaks down the modus vivendi of a weak heart. 
Constipation is the special danger of old age, and the indirect cause 
of death to numberless old people. It is not inconsistent with a daily 
action of the bowels, the relief being incomplete ; so that gradual 
accumulation of faecal matters takes place, and so-called diarrhoea in 
old people is very often a symptom of such accumulation. The pres- 
ence of scybala gives rise to frequent calls to the stool, and all that 
escapes is a little liquid consisting of secretion from the mucous 
membrane of the rectum stained by debris washed from the surface 
of the hard masses. 

Pathological Effects of High Tension, — The pathological changes 
resulting from unduly high tension must now be traced in the arte- 
rioles, arteries, and heart. 

Hypertrophy of Muscular Coat of Arteries and Fibroid Change. 

Rupture of Vessels, — The most common and serious effect on 
arterioles of the smallest size is cerebral hemorrhage from rupture 
of terminal branches of cerebral arteries. 

Atheroma and Degeneration of Small Arteries. — Atheroma of 
aorta and its consequences. The constant stress on their walls sets 
up a chronic inflammatory process ; degenerative changes follow ; 
the lining membrane of the vessels gives way, and the excluded 
matter is gradually carried off by the blood. Another secondary 
effect of aortic atheroma is narrowing of the orifices of the coronary 
arteries. This, with extension of atheromatous disease into these 
arteries from the aorta, is the most common cause of fatty degenera- 
tion of the heart, which must thus be set down as one of the con- 
sequences of high arterial tension. 

Diseases of Valves of the Heart. — Valvular disease, properly 
speaking, is also set up by high arterial tension. 



DISEASES OF THE HEART. 775 

Hypertrophy of Heart Walls. — On the heart walls the first and 
most constant effect is the production of hypertrophy. 

Dilatation of the Heart. — Dilatation is another common result, 
either preceding hypertrophy, or associated with it from the begin- 
ning, or supervening at a later period. 

Glaucoma. — The characteristic feature of which is intra-ocular 
tension, under which the globe of the eye becomes bullet-hard and 
the optic disc cupped. 

" Cheyne- Stokes' Respiration" says Broadbent, " has, in my ex- 
perience, been so constantly associated with high arterial tension that 
I feel justified in looking upon it as an effect of this condition of the 
circulation, not indeed, perhaps, simple and direct, but in the sense 
that high pressure in the arterial system is, if not a necessary, yet 
the most constant recognizable factor. " 

Symptoms Attending High Arterial Tension. — Among the more 
frequent and important of these symptoms are headache, sleepless- 
ness, breathlessness, depression ; loss of energy, resolution, memory, 
and nerve ; giddiness, a sense of fulness in the head, pain and oppres- 
sion in the chest, and neuralgia. Headache may vary in seat, char- 
acter, and duration. It may be frontal, occipital, or vertical. It 
is sometimes a morning headache, which disappears after the bath 
and breakfast ; at others it comes on after mental work or towards 
the end of the day. Headache is very common in the subject of high 
arterial tension, but high tension has no specific form of headache. 
Migraine, or sick headache, again, is, according to my experience, 
almost always associated with high tension, not only during the 
attacks, but as an habitual condition, and the liability runs in high 
tension families. 

" Neuralgia, not of migraine character, is one of the less common 
effects of high tension, and it is only mentioned because we should 
not under ordinary circumstances think of resorting to the treatment 
suggested. I have, however, seen neuralgia cured by a dose of cal- 
omel when all other remedies, including change of air, had failed to 
give relief. The patients were pale and weakly ladies, and were not 
suffering from constipation. Calomel, therefore, appeared to be con- 
tra-indicated, and was only at length given because of the high arte- 
rial tension which had been noted throughout." Depression of spir- 
its, loss of the power of concentrating the attention, impairment of 



776 THE PRACTICE OF MEDICINE. 

the memory, painful irresolution, irritability of temper, and loss of 
nerve are other symptoms commonly met with in association with 
high arterial tension. Breathlessness on exertion, as severe as in 
advanced heart disease, may be simply the result of high tension ; 
the resistance in the peripheral vessels may have an effect on the cir- 
culation equivalent to that of valvular disease or dilatation of the 
heart. I have seen several cases in which the patient has been com- 
pelled to stop and sit down or support himself by railings, gasping 
for breath, two or three times in the course of a few hundred yards 
of level walking at a slow pace, no cause for this being recognizable 
in the heart, and complete and permanent relief being afforded when 
extremely high tension was reduced. 

Treatment. — It would not be good practice to prescribe for high 
tension alone, unless there was such an absence of concomitant symp- 
toms as to warrant it. Such a condition is fortunately rare, but 
when it does occur we should not hesitate to prescribe for the one 
symptom. We will then have to decide whether the high tension is 
due to vaso-motor irritation or atheroma. If the former, aconite, 
glonoine, mercury, veratrum viride, and gelsemium are the physio- 
logical remedies. There are a few of our school who object to the 
use of the word physiological as applied to the effects of medicines, 
and insist that the word pathogenetic should be used. I cannot agree 
with them. The word pathogenetic means disease-causing. I use 
the word physiological in the sense that a medicine is capable of 
changing an abnormal process to a normal one by exerting its pri- 
mary action with the effect of restoring normal physiological action. 
For example : a patient has a hard incompressible pulse ; the artery 
feels like a cord between the beats. If the artery is at the same time 
narrowed give aconite lx, a drop every hour, and in less than twenty- 
four hours the pulse is normal. Then suspend the medicine and the 
condition does not return. Other remedies for new symptoms may 
be needed, but we have perhaps arrested a condition which might 
have proved serious. If the pulse is full, hard, and forcible, veratrum 
viride lx is the remedy. Neither of these remedies require the pres- 
ence of fever to make them fully indicated in a condition of high 
arterial tension. 

When high tension is caused by some toxic material in the blood 



DISEASES OF THE HEART. TIT 

there is no drug equal to mercury to aid in its elimination, when this 
toxic material is generated in the liver or intestines. 

Broadbent gives the following indications for mercury, and I have 
often verified his experience. 

" An attack of apoplexy may be staved off by a timely dose of 
calomel, and by the same means a laboring heart, unable to cope 
with the resistance in the arterioles and capillaries, may be at once 
relieved. The great remedy for mischief of any kind impending as 
a result of high blood-pressure is a mercurial purge. The effect of 
mercury employed as an aperient upon abnormal tension in the 
arteries is a matter of observation. The method by which the effect 
is produced is a question of hypothesis, but there can be no doubt 
that it is by elimination, and there need be little hesitation in con- 
cluding that the seat of the accelerated metabolism — of which the 
elimination is a resultant — is the liver. Such, at any rate, is the 
working hypothesis by which I am guided. It may be added, per- 
haps, that I entered upon the independent study of medicine fully 
impressed with the view of teachers held in high respect and confi- 
dence, who considered that the action of mercury on the liver had 
been entirely disproved, and that mercury, indeed, had practically no 
useful place in medicine, and that it has been from my experience of 
its effects on blood-pressure that I have come to value it as one of 
our most important remedies. Full doses of calomel being reserved 
for emergencies, the less serious symptoms may be met by the admin- 
istration of a single grain of pil. hydrarg. with ipecac, and rhubarb 
or colocynth twice or three times a week, with which may be com- 
bined from time to time a three-weeks' course of mild salines. To 
intermediate degrees of urgency may be adapted suitable doses and 
combinations." 

The rhubarb and colocynth can be left out. I like the combina- 
tion of mercurius dulcis and ipecac — one-tenth of a grain of each 
in a tablet ; dose, one to five. One every hour will often act as an 
active laxative in a few hours. 

If high tension is persistent and there is reason to believe that 
degeneration of the arterial coats has commenced, the patient should 
be put upon the use of iodide of potassium or the iodide of sodium 
in material doses — one to five grains three times daily. This should 



778 THE PRACTICE OF MEDICINE. 

be continued for weeks, or until the condition is ameliorated. In 
cases where rheumatism is present, iodide of lithium is superior. 

Phytolacca is an excellent medicine in high arterial tension. It 
resembles very closely iodide of potassium, and will often relieve 
when the iodides have failed. 

Glonoine is indicated in cases of acute, sudden, and intense vaso- 
motor spasm such as occurs in plethoric, apoplectic, and neurotic 
persons, and chronic cases due to atheroma, or persistent contrac- 
tion of the arteries. As a rule a drop of the 1c. (one per cent solu- 
tion) is sufficiently strong in acute cases, but we should not hesitate 
to increase the dose until the arteries relax. Cases are on record 
where the dose had to be increased until one-tenth and even one-fourth 
of a grain had been given before relief was obtained, and these doses 
were given every four to six hours without unpleasant symptoms, 
but with decided benefit, and continued for weeks. The reader may 
ask, why do you not recommend the medicines whose primary action 
is to cause high arterial tension ? I answer that I have tried them 
in high and medium attenuations, and they have disappointed me. 
I have given digitalis, ergot, hydrastis, cactus, nux vomica, and 
others which primarily contract the arteries and increase the blood- 
pressure ; and I have prescribed them in the 6th, 12th, and 30th, 
but I have never seen them modify this condition. I make no attempt 
to explain this apparent failure of the law of similia. 

In anaemia with high tension, glonoine has been combined with 
some preparation of iron with excellent results, when iron alone 
failed to produce benefit. Ferro-cyanuret of potassium will give 
the same results, for the hydrocyanic acid is a relaxant of arterial 
tension. 

Constipation is a common cause of high tension due to the gen- 
eration in retained faecal matter of poisonous ptomaines and leuco- 
maines. In such cases mechanical means like the colon-douche or 
active purgatives are imperatively demanded. The physician who 
allows faecal poisons to accumulate in the system is guilty of mal- 
practice, as much as if he allowed a foreign substance to remain in 
a wound, or septic material to remain in the uterus. The high ten- 
sion of Bright's disease should be treated with glonoine, muriate of 
gold, sweet spirits of niter, hot sitz baths, vapor baths, diuretin, and 
other medicines which relax the tension of the renal arteries and 



DISEASES OF THE HEART. 779 

allow the urinary poisons to be carried off. If this is not promptly 
done uraemia will result. Hysteria and some forms of neuralgia are 
perhaps due to high tension. At any rate I have observed that when 
the pulse is rendered full and soft by gelsemium, lobelia, asafoetida, 
castoreum, and moschus, the hysterical manifestation subsided. As 
Dunham pointed out, platina is the true similimum of hysteria with 
spasm of the arterioles. In some cases it will cure, but its failures 
are many. 

Camphor will primarily cause high arterial and capillary tension 
with apparent collapse and convulsions, and secondarily the opposite 
condition of low tension with fainting and cramps. This was observed 
by Hahnemann who considered them " alternating " symptoms. Nux- 
moschata has similar effects. If ferrum phos. is indicated by the 
symptoms (and not according to Shuessler's baseless theory) it will 
prove in minute doses an excellent remedy in the high tension of 
plethora, but its action should be aided (in plethora) by a light non- 
nitrogenous diet, copious libations of pure soft water, the use of 
saline laxatives and a good deal of active exercise or labor. With 
this regimen, and the administration of phytolacca, veratrum viride, 
and iodide of sodium, I have seen dangerous plethora with impend- 
ing apoplexy improve rapidly in a few weeks. 

Angina pectoris, and what is called angio-spastic neuralgia and 
headache, is but a manifestation of intense arterial tension combined 
with spasm. They may have their origin in irritation of the medulla, 
or be caused by morbific substances in the blood. These painful affec- 
tions require promptly acting remedies, and it has been found that 
moist heat (not over 100° F.) applied locally is one of the best means 
of relief. If too hot, the heat will aggravate the spasm. In acute 
cases amyl or ether will give immediate relief, and glonoine lc, bel- 
ladonna lx, veratrum album 3x, spigelia 3x, phenacetin lx, caf- 
feine lx, and antipyrine lx, will often relieve quickly. 



LOW ARTERIAL TENSION. 

This is not a disease but the consequence of many abnormal states. 
Dr. Broadbent, in discussing this condition of the pulse, says : 

" Whether the freedom of flow through the peripheral vessels is 
•determined entirely by changes in the size of the arterioles, or is 



780 THE PRACTICE OF MEDICINE. 

influenced primarily by the degree of obstruction in the capillaries y 
it must be admitted at once that the muscular walls of the minute 
arteries respond more promptly and energetically to nervous stimuli 
than the capilaries ; and in emotional and reflex influences upon the 
peripheral circulation there can be little doubt that spasm or relax- 
ation of the arterioles is the mechanism employed. When, for exam- 
ple, there is from nervousness sudden and fugitive high arterial ten- 
sion, it is in part due to tightening up of the minute arteries, and 
not solely to the hurried and forcible action of the heart ; and in 
blushing, it is relaxation of the arterioles of the affected region 
which allows the skin of the face and neck to be flooded with blood. 
Such relaxation may be partial, as is frequently seen on exposing the 
chest in young women for the purpose of stethoscopic examination, 
when it is found to be covered with large bright-red blotches. But 
while the arterioles are competent to influence the supply of blood to* 
different parts and organs of the body> and undoubtedly play an im- 
portant part in regulating this, in doing which they will produce cor- 
responding effects on the arterial tension by opposing or facilitating 
the flow in the capillaries, it is probable that the capillaries them- 
selves are the seat of the principal obstruction to the onward move- 
ment of the blood, and of those variations in the degree of obstruc- 
tion which are most influential in modifying the blood-pressure. It 
is indeed certain that it is in the capillary network that the normal 
physiological resistance in the peripheral circulation takes place, and 
it is only here that the resulting pressure could have the effect which 
it subserves, of promoting the transudation through the capillary 
walls of nutrient material for the use of the tissues. Up to the very 
edge of this network the blood-pressure in the arteries and arteri- 
oles is maintained ; beyond it there is only just sufficient to carry 
the blood back to the heart in the veins. We might reasonably 
expect, then, that where the resistance which gives rise to the press- 
ure in the arterial system is originally situated, there would arise 
those differences in the degree of resistance which affect arterial ten- 
sion. Evidences in favor of this view are not wanting. 

The relaxation and contraction of the arterioles are reflex, or, at 
any rate, take place in response to stimulation of their muscular 
walls by the vaso-motor sympathetic nerves ; but experiments with a 
variety of drugs have shown that variations in the rate of flow through 



DISEASES OF THE HEART. 781 

the capillaries and in the arterial tension can be induced when the 
spinal cord and sympathetic ganglia and nerves are destroyed, i. e., 
when the vaso-motor nervous apparatus is abolished. Drs. Ringer 
and Saintsbury have described such experiments made with the dig- 
italis group of remedies (" Med. Chir. Trans.," lxvii.), and corres- 
ponding results have been obtained with amyl nitrite and other relax- 
ants of the peripheral vessels by Dr. Lauder Brunton. 

" Although it appears from the preceding considerations that the 
starting point of the physiological resistance in the peripheral circu- 
lation and of the variations in this resistance is the capillary net- 
work, the arterioles are not without an important share in the pro- 
cess. The contraction of the capillaries is continued backwards 
along the arterioles to arteries of the size of the radial, and the nar- 
rowing of the afferent channels thus produced at the same time con- 
tributes to the production of the arterial tension, and protects the 
capillaries from the afflux and pressure of blood ; in like manner 
when the capillaries are relaxed, the arterioles and arteries are large. 
The arteries and capillaries, in fact, form part of one system, and 
the expression 4 arterio-capillary resistance ' is more exact than when 
an obstruction is qualified as either arterial or capillary alone. The 
capacity of the arterial system, as has already been stated, increases 
with the subdivision of the arteries, and the capillary channels are 
collectively much larger than the arterioles which supply them ; it 
is conceivable, then, that the outflow might be so free, in spite of the 
friction between the blood and the walls of the containing vessels, 
that it would pass onward into the veins as it was injected by the 
heart into the aorta. Of course the same amount of blood does pass 
through the capillary network generally at each pulsation as is pro- 
pelled by the corresponding ventricular systole, but the systole is 
effected in one-third of the time occupied by the entire cardiac rev- 
olution, so that the blood is three times as long in escaping by the 
capillaries, and there are accumulated in the arteries, distending 
them and bringing into play the elasticity of their coats, a consider- 
able number of charges of the ventricle. In proportion as the flow 
through the capillaries is free, the number of heart-beats stored up 
in the arteries will be diminished, the mean of continual blood-press- 
ure within them and the degree of tension of their coats will be low- 
ered, and, most important of all, the smaller will be the amount of 



782 THE PRACTICE OF MEDICINE. 

nutrient material passing through the capillary wall for the use of the 
structures. Low arterial tension, which is now to be considered, then, 
implies a diminished arterial reserve and a lessened supply of nour- 
ishment to the tissues. 

" Characters of Low- Tension Pulse. — The essential characters of 
the low-tension pulse are, that the artery is so readily effaced by 
moderate pressure that it cannot be felt at all between the beats. 
It seems to start into existence with each pulsation, and to disap- 
pear as the wave passes. 

"Varieties of Low- Tension Pulse. — There are many varieties 
of low-tension pulse, according to the frequency and force of the 
heart-beats. When the heart is acting forcibly the pulse is large, 
sudden, and vehement (full and bounding), the size of the dilated 
artery and the shortness of the wave intensifying the impression of 
force conveyed to the fingers. The force and frequency of the sys- 
tolic discharge of blood into the aorta may be such as to maintain 
a degree of fulness of the arterial system in spite of the free outflow 
by the capillaries, and the radial can then be felt between the beats 
when only moderate pressure is employed. It can, however, be flat- 
tened without difficulty. Dicrotism is, of course, distinct. 

" When the heart acts feebly, or sends out a diminished amount 
of blood at each systole, the diminished amount of blood in the arte- 
rial system allows the arteries to contract, and the pulse will be small 
and very easily suppressed. 

" Causes of Low- Tension. — As with the time of the heart so 
with the tone of the arteries ; there are variations on each side of 
the normal average without apparent effect on the health and vigor, 
and a low-tension pulse may be congenital, or it may run in a fam- 
ily. It is sometimes important to bear this in mind ; absence of a 
proper degree of tension is one of the signs of fatty degeneration of 
the heart, and when present after middle age, together with symp- 
toms of cardiac debility, it might lead to an erroneous diagnosis of 
this disease. A medical man who knew the family pulse to be soft 
would be in no danger of making this mistake. Obesity is usually 
associated with low-pulse tension, the arteries also being small and the 
action of the heart weak. It is not unlikely that the languid move- 
ment indicated by these conditions may favor the deposition of fat. 



DISEASES OF THE HEART. 783 

Warmth, especially combined with moisture, relaxes the arterioles 
and capillaries, and lowers the arterial tension ; a hot bath will do 
this very effectually. Food, particularly when taken warm ; hot 
drinks, sustained exertion, fatigue, and exhaustion, bodily or men- 
tal, are other physiological causes of relaxation of the peripheral ves- 
sels. As regards the effect of a meal in lowering the pulse tension 
at the wrist, it might be attributed to the large diversion of blood to 
the abdominal viscera during digestion, but this will be compensated 
in some degree by the increased volume of the blood by rapid absorp- 
tion from the gastro-intestinal mucous surfaces. It is, moreover, 
evident from the character of the pulse that the arteries are relaxed 
and large, and not simply unfilled. We see, too, in the flushed face 
and red nose of certain forms of dyspepsia, especially in women and 
young girls, a local exaggeration of the general arterial relaxation. 
Anxiety, worry, and the depressing emotions ; inadequate food or 
deficiency in the nitrogenized constituents of food, occasionally excess- 
ive indulgence in alcohol, and various unfavorable hygienic influ- 
ences, may give rise to low arterial tension. Debility of certain 
kinds is attended with low blood-pressure, but anaemia, especially 
when associated with chlorosis, often has a high-tension pulse. 

Certain states of the nervous system are associated with low-pulse 
tension. Sometimes it is the affection of the nervous system which 
causes the low tension, sometimes it is absence of due intra-arterial 
pressure, which gives rise to the morbid condition of the nerve cen- 
tres. This subject will be discussed later. The most common cause 
of relaxation of the arterioles and capillaries and of low tension in 
the pulse, however, is pyrexia. 

Effects of Low Arterial Tension. — Deficient resistance in the 
peripheral circulation, and consequent abnormally low pressure, are 
not likely to affect injuriously the heart or arteries directly, and no 
morbid change in either has been traced to low-pulse tension. The 
nutrition of the tissues generally will not, however, be maintained 
at a high point, and the heart will share in the imperfect renewal 
of structures, especially as the blood-pressure in the coronary arter- 
ies will be low, and the movement of blood in the walls of the heart 
languid. Moreover, the heart is not called upon to exercise full 
normal energy ; and just as overwork in consequence of high arte- 



784 THE PRACTICE OF MEDICINE. 

rial tension gives rise to hypertrophy, underwork will tend to atrophy. 
It is possible, then, that low-pulse tension may predispose to cardiac 
degeneration. 

Symptoms. — The symptoms associated with a pulse of low ten- 
sion are extremely varied, and they are, for the most part, not the 
result of the weak pulse, but concomitant effects of an underlying 
cause. Many of them are equally common when the pulse tension 
is high, and the question is not what symptoms arise out of low or 
high pressure in the arteries, but, given certain symptoms, what is 
the state of arterial tension, since this is an important guide in the 
treatment. It has appeared to me that undue relaxation of the small 
arteries is sometimes a cause of weakness and depression by permit- 
ting undue loss of heat. It is the duty, so to speak, of the arterioles 
to shut off the blood from the surface of the body on exposure to 
cold, and thus to protect it from being cooled down. When this 
function is imperfectly performed the skin and the extremities may 
be warm in spite of very low external temperature, but the body must 
lose heat rapidly from exposure to cold of successive portions of 
blood distributed freely to the skin, and either the temperature of 
the body generally will fall, or increased oxidation and tissue change 
will be required in order to keep it at normal level. In either case 
the tax on the system will be heavy, and only a vigorous constitution 
<?an support it with impunity. A sufferer from the depression pro- 
duced in the way just described will often exhibit his warm hands 
and boast of his warm feet as proofs of his excellent circulation. 

Abnormally low pulse tension may be associated with a great 
variety of functional derangements, as well as of symptoms ; dys- 
pepsia, constipation, sleeplessness, headache, and a multiplicity of 
pains and sensations in the head, or about the heart, or in the back ; 
and when flatulent dyspepsia and constipation are present it is some- 
times a defensible hypothesis that the depression and other nervous 
symptoms may be due to the gastro-hepatic or intestinal derange- 
ment, and the rectification of all recognized departures from func- 
tional efficiency and regularity would be one of the first objects of 
treatment. It is worthy of note, however, that when the pulse ten- 
sion is low the patient often feels better while the bowels are con- 
fined, and depressed and faint for some time after any action, either 



DISEASES OF THE HEART. 785 

spontaneous or however induced. Such patients bear purgatives of 
all kinds badly, especially when mercury in any form enters into 
their composition. Low arterial tension in diseases usually attended 
with high tension is prognostic of evil. This is especially the case in 
kidney disease. 

Treatment. — " In speaking of treatment," says Dr. Broadbent, 
" it is scarcely necessary to say that it is not treatment of low ten- 
sion as such, but of cases in which low arterial tension is a promi- 
nent symptom. The first point to be considered will be whether the 
imperfect resistance in the arterio-capillary system of vessels is due 
to the state of the blood and tissues, or to deranged nervous influ- 
ence. It is not easy to establish such a distinction, for under the 
influence of mental shock, or grief, or anxiety, anaemia may super- 
vene with extraordinary rapidity ; and, on the other hand, deterio- 
ration of the blood and tissues may react upon the nervous system. 
Iron, the mineral acids, arsenic, phosphorus, nux vomica, or strych- 
nine, quinine, bark, are among the medicaments most generally use- 
ful ; digitalis, again, the special tonic of the heart and arterioles, 
may be of service." 

There is no particular objection to the medicines mentioned if 
they are given according to their secondary symptoms. Their pri- 
mary effects, when given in physiological doses, are just the opposite 
of low arterial tension, but in poisonous doses they cause collapse of 
pulse from heart failure or tetanic systole. Low arterial tension or 
weak pulse is generally only a symptom of failing vital force. To 
prescribe for this symptom alone, except in sudden shock, is not 
good practice. We should try to ascertain the causes which have 
led to that condition. If from mental shock, like grief, or disap- 
pointment, phosphoric acid and ignatia are potent remedies. I well 
remember several cases where disappointed affection in young girls 
caused rapid anaemia with extreme low tension, which continued long 
after the shock, and I remember how rapidly they recovered under 
the use of the two potent remedies mentioned. 

If the low tension is due to impoverished blood, one of the prep- 
arations of iron should be given, but we should remember that 
iron alone will not cure anaemia. The patient must have the revivi- 
fying influence of open air, change of climate, and properly selected 



786 THE PRACTICE OF MEDICINE. 

food. Cinchona, helonias, aletris, hydrastia, nux vomica, ignatia, 
and arsenic are great aids to the action of iron, and in some cases 
will cure anaemia without the use of iron. 

We must discriminate between acute and chronic low arterial 
tension. The former simply requires rest, good food, mild stimu- 
lants, and a little medicine. If the result of diarrhoea, or a brief 
fever, china, veratrum album, ipecac, or iris will be the most useful 
medicines. When arterial low tension has lasted sometime, the 
nutritive processes suffer. There will be as a result emaciation, 
debility, atony of all the muscular structures, and torpidity of the 
assimilative organs. Medicines which arouse the nutritive functions 
must be given. Generally the drugs which cause primary low ten- 
sion are not indicated, but such medicines as arsenic, phosphorus, 
phosphoric acid, sulphur, nitric and muriatic acid. Nux vomica, 
strychnia, helonias, sepia, graphites, calcarea phos., picric acid, 
hydrastis, and cinchona are appropriate. All the above, except 
sepia, graphites, calcarea, and picric acid (which act best at the 6th 
trit.) should be given in the lower attenuations. If the emaciation 
is extreme, cod-liver oil is of great service. If this is repulsive, give 
morrhual, which contains all the inorganic constituents of the oil, 
and will restore the assimilative functions in a surprising manner. 
Steam's wine of cod-liver oil is a more pleasant preparation than 
the sugar-coated pills of morrhual, and will be readily taken by chil- 
dren. An excellent tonic to the nutritive functions is a syrup of 
hypophosphites with saw palmetto. 

When the heart remains weak and does not fill the arterioles, 
notwithstanding the medicines above named, special cardiac tonics 
should be associated with them. A few drops of the tincture of dig- 
italis, cactus, strophanthus, oleander, coronilla, or kola, given three 
times a day, will greatly aid the restorative action of food and med- 
icines. Whatever treatment we adopt, it should be faithfully con- 
tinued for weeks or even months. 

The question of rest, or work, is of great importance. Often the 
surest way to bring about recovery is the adoption of the Weir 
Mitchel treatment of absolute rest and feeding. In other cases a 
life of physical activity in the pure open air is the sine qua non. 

The food will, of course, be simple, nourishing, and digestible. 
Alcohol will be given with caution at meal-times only, and in the 



DISEASES OF THE HEART. 787 

form of red wine or beer. Change is often of the greatest service, 
the most powerful climatic influence being sea or mountain air, one 
or the other being selected, according to the previous experience of 
the patient. 

While absence of resistance in the peripheral vessels is the nor- 
mal cause of low tension in the arteries, it is obvious that, since the 
blood-pressure is ultimately due to and dependent upon the ventri- 
cular systole, the tension must be low when the propulsion of blood 
into the arterial system is feeble or deficient in amount. In the lat- 
ter case, however, the arteries contract upon their contents, still 
remaining full between the beats, and the pulse becomes small with- 
out necessarily being short. Usually, relaxed arteries and capil- 
laries and weak action of the heart go together, or the circulation 
would come to a standstill. 

Bathing is an important agent in low arterial tension, especially 
when the capillary system is at fault. Prolonged warm or hot baths 
are injurious, but cold or hot sponging when rapidly done is bene- 
ficial ; so also is the momentary rain or shower bath. 

Charcot, of Paris, uses the cold douche thrown from a small noz- 
zle with considerable force, but only for a minute. 

After the baths brisk friction should be used until the skin is 
aglow. 

THE PULSE. 

No work on the diseases of the heart and blood-vessels can be 
said to be complete unless it has as an introduction a chapter on the 
Pulse. 

No correct idea of the significance of the pulse and its relation to 
the condition of the heart was possible until the discovery of the cir- 
culation of the blood by Harvey in 1628. In Dr. Ozanam's work 
" On the Circulation and the Pulse" he gives the best historical 
account of the history of the pulse. 

The earliest idea of the pulse was that the arteries were filled, 
not with blood, but with a vital air or spirit. It was supposed that 
the veins carried the blood to every part of the body and that they 
had their origin in the liver. It was a great discovery when Galen 
proved that the heart and arteries contained blood. But he still 



788 THE PRACTICE OF MEDICINE. 

believed that the liver was the manufactory of the blood, and that 
the heart drew the blood to itself from both veins and arteries. 

The first treatise on the pulse was written by Herophilus 344 
years before the time of Christ. Since that time there have been 
many, and some of them very voluminous, but his observations are 
very instructive even at this day. The recent writers on the pulse 
and the most thorough investigators are Volkman, Ludwig, Chaveau, 
Marey, the brothers Weber, Henle, Stilling, Claude Bernard, and 
Brown-Sequard. The latest and most practical of all the treatises on 
this subject is that of Dr. W. H. Broadbent, of London, which 
should be in the hands of every practitioner of medicine. It is 
invaluable as a means of diagnosis and prognosis. 

In the following chapter on the Pulse I shall quote extensively 
from his work,* for quotations give clearer information than any 
synopsis I could make. 

WHAT THE PULSE REALLY IS. 

" Now it is not," writes Dr. Broadbent, " as is commonly under- 
stood, an expansion of the artery. This at any rate is not what we 
feel or what is recorded by the sphygmograph. A moment's reflec- 
tion as to the volume of blood discharged by the left ventricle into 
the aorta, and a comparison of this with the capacity of the entire 
arterial system, will convince us that it is altogether inadequate to 
produce any such expansion of the smaller arteries as will be appre- 
ciable to the touch. The aorta and its primary branches are, it is 
true, dilated somewhat by the injected blood ; but even in a vessel 
of the size of the carotid it is difficult to measure the increase of 
diameter, so minute is it ; whereas in the radial, in which it must be 
much less, the sphygmograph, if its trace were taken to indicate 
actual enlargement of the artery, would show the expansion to be con- 
siderable. Nor is the pulse a sinuous movement of the artery in its 
bed from elongation which throws it into curves. To feel the pulsa- 
tion in an artery, or to take a sphygmographic trace, a certain degree 
of pressure must be applied to the vessel, and, as is well known, 
there must be a bone behind it against which it can be compressed. 

*The Pulse. By W. H. Broadbent, M.D. Pp. 306. Philadelphia: Lea 
Brothers & Co., 1892. 






DISEASES OF THE HEART. 789 

What happens then is as follows : in the intervals between the 
pulsations, when the resistance by the contained blood is at its low- 
est, the tube of the artery is more or less flattened by the pressure 
of the finger upon it ; then comes the so-called wave of blood pro- 
pelled by the systole of the left ventricle, or, to speak more accu- 
rately, the fluid pressure in the vessel is increased, and this forces the 
artery back into the circular form. It is this change of shape from 
the flattened condition impressed upon the vessel by the finger, or by 
the sphygmographic lever, to the round cylindrical shape which it 
assumes under the distending force of the blood within it which con- 
stitutes for us the pulse. Such a pulsation can be felt on a large 
scale by placing the foot on the inelastic leather hose of a fire engine 
in action, in which there can be no expansion, or shown in a scheme 
of the circulation with inelastic vessels. It is not, then, an increase 
in the diameter of the vessel, but an increase of the blood-pressure 
within it, created by the systole of the ventricle of the heart, which 
constitutes the pulse. Another common misconception must be 
cleared up, namely, that the pulse necessarily signifies onward move- 
ment of the blood in the artery. Since a certain amount of blood 
is normally injected into the aorta at each systole, it would seem, at 
first sight, that there must be a corresponding propulsion of blood 
along the vessel which is under the finger, and misapprehension has 
been carried so far that the pulse-wave has been understood to mean 
the actual transport of the blood, and even to indicate the rapidity 
of such motion. Short of this, it is more commonly taken for granted 
that the rate of movement of the blood in the vessels is directly pro- 
portionate to the strength of the pulse — that a good strong pulse 
implies a vigorous rush through the capillaries, and a weak pulse a 
languid flow. The stream which issues from a divided artery is 
compressed close to the hand, the pulsation above is not extinguished, 
but exaggerated ; and when an artery is tied, the pulsation up to 
the ligatured point is more vehement than before. Pulsation is thus 
no evidence of onward movement of the blood. Now, resistance in 
the arteries and capillaries will have, pro tanto, the effect of a liga- 
ture, hindering or even arresting the onward current. And there 
can be no doubt that peripheral obstruction does at times reach a 
point which almost stops the flow from the arteries to the veins, the 
pulse appearing to be all the stronger on this account. The heart 



790 THE PRACTICE OF MEDICINE. 

acts with increasing energy in order to combat the obstruction, but 
may fail so far to overcome it as to propel an average amount 
of blood into the aorta, although it raises the pressure through- 
out the arterial system. This is a consideration which, it seems to 
me, is not adequately borne in mind. I think it enters into the 
explanation of dropsy, and especially of the varying amount of drop- 
sical effusion under apparently similar conditions, and that it also 
helps to clear up obscurities in the relation between circulatory con- 
ditions and head symptoms. 

The pulse, then, indicates simply the degree and duration of in- 
creased pressure in the arterial system caused by the ventricular 
systole. There is a certain mean blood-pressure maintained by the 
elasticity of the large arteries, varying greatly in different individ- 
uals, which keeps up the flow through the capillaries, and the level 
of which is determined by the resistance in the capillaries and the 
amount of force received from the heart and stored up by the elastic 
walls of the large arteries. This pressure is lowered during the 
diastole of the heart by the outflow through the capillaries into the 
veins, and is reinforced by the successive contractions of the left 
ventricle, and the pulse marks and indicates the minimum and max- 
imum pressures, with the gradation from one to the other. The term 
" tension," as applied to the pulse, means simply the degree of fluid 
pressure within the artery, putting its walls on the stretch. 

Arterial tension and blood-pressure mean exactly the same thing. 
Distension might perhaps be more expressive than tension, if less 
exact and technical. There are three factors in the production of 
the pulse, and the influence of each on the variations observed in it 
must be understood. The three factors are : 

(1) The action of the heart. 

(2) The elasticity of the great vessels. 

(3) The resistance in the arterioles and capillaries. 

The heart determines unconditionally the frequency and regular- 
ity or irregularity of the pulse, and, with certain qualifications, its 
force or strength. The great vessels, acting as an elastic reservoir, 
convert the intermittent jet issuing from the ventricle into a more 
or less continuous stream, impressing at the same time certain char- 
acters upon the pulse according as the elasticity of their walls is per- 
fect or impaired, and according as they are kept fully distended or 



DISEASES OF THE HEART. 791 

only slightly on the stretch. The capillaries and arterioles, by the 
varying resistance which they offer to the passage of blood through 
them, determine the mean pressure maintained in the arterial system 
and the character of the pulse, and influence materially the action of 
the heart. Each of these must be considered in some detail." 

Dr. Broadbent then goes on to explain the relations and influence 
of the heart on the various conditions of the pulse, as follows : 



THE ACTION OF THE HEART. 

" Frequency. — The heart determines absolutely the frequency of 
the pulse ; and this is true in so far that the number of heart-beats, 
except when a certain proportion of the latter are too weak to reach 
the wrist, or when very little blood enters the ventricle during its 
diastole. 

" Rhythm. — The rhythm, as well as the rate, of the pulse is de- 
termined by the heart, and the pulse, generally speaking, is regular 
or irregular according as the action of the heart is regular or irreg- 
ular. The pulse, however, may be made irregular when the heart is 
acting regularly by beats failing to reach the wrist, and irregularity 
of the heart's action may be greatly exaggerated in the pulse. 

"Force. — With regard to the strength or force of the pulse, again, 
this must be directly dependent upon the strength of the ventricular 
systole. The pulse cannot be strong or forcible when the heart's 
action is weak, and it will not, as a rule, be weak when the heart's 
action is vigorous. But the volume of blood discharged by the ven- 
tricle into the aorta is another element in the production of the pulse. 
If from any cause the ventricle is not properly filled, as may be the 
case when the total volume of the blood has been reduced by hemor- 
rhages or other cause, or when there is obstruction in the pulmonary 
circulation, from disease of the lungs or extreme constriction of the 
mitral orifice, or when the ventricle has not time to dilate, as may 
bappen in palpitation, the systole, however forcible, will have little 
effect in increasing the pressure in the arterial system ; and there 
may, under such circumstances, be powerful action of the heart with 
a feeble pulse. It will also be seen, when the influences of periph- 
eral resistance is discussed, that the apparent strength of the pulse 
may not correspond with the energy of the ventricular contraction, 



792 THE PRACTICE OF MEDICINE. 

even when the amount of blood propelled is normal ; and the blood- 
pressure or arterial tension, i. e., the degree of distension of the ar- 
teries while it is maintained by the heart, and is dependent upon the 
degree of pressure supplied by the ventricular systole, is by no means 
necessarily proportionate to its vigor." 

Of the functions of the great arteries Dr. Broadbent says : " The 
principal effect of the large arteries is to act as an elastic reservoir, 
which converts the intermittent jet of blood which issues from the 
ventricle into a continuous stream. They are kept by the resistance 
to the outflow through the capillaries in a state of continual disten- 
sion, which is increased momentarily by each ventricular systole, and 
runs down to some extent in the intervals, but never during life to 
a point at which the elastic coats of the vessel cease to exercise some 
compression on its contained blood. The force of the heart is thus 
stored up and delivered out gradually in the form of a steady press- 
ure, which keeps up an almost uniform flow through the vessels of 
the periphery. The regular current of blood sustained in this way 
is essential to the functional activity of the central nervous system. 

The Sphygmograph. — " In recent teachings with regard to the 
circulation and the pulse, the constant reference to the sphygmo- 
graph has been an obstacle to the application of the newly-obtained 
knowledge to clinical work, and especially to everyday practice. 

" The sphygmograph has been invaluable in research ; it has given 
precision to our ideas, and in the hands of Marey and others has 
made clear and comprehensible many intricate and doubtful prob- 
lems of the circulation. It is capable, too, of rendering important 
aid in clinical investigation, especially where demonstration and 
records of changes in the circulation are required. 

" It is not, therefore, from ignorance of or want of familiarity 
with the sphygmograph that I have come to the conclusion that it is 
not specially useful in practice, that in any form known to me it is 
not a clinical instrument for everyday work. It is rarely necessary 
for diagnosis, and scarcely ever to be trusted in prognosis. The indi- 
cations obtained from it are not, like those of the thermometer, inde- 
pendent of the observer." 

The above remarks by Dr. Broadbent confirm my opinion as to 
the practical value of the sphygmograph. He is well qualified to 
express an opinion on its merits, for no man has had larger oppor- 



DISEASES OF THE HEART. 793 

tunities of testing its usefulness. He shared the enthusiasm of Anstie, 
Sanderson, and Sibson, when the instrument first appeared. He ad- 
mits its value in physiological investigations, and some pathological 
changes, but such is the amount of skill and precision necessary to 
its use, that few can perfect themselves in it. 



MODE OF FEELING THE PULSE. 

" In examining the pulse," says Dr. Broadbent, " our object is 
to obtain the most complete and exact knowledge attainable as to 
the circulation and to interpret accurately the facts we observe ; the 
method to be followed must therefore be carefully described. Three 
fingers should be placed on the artery, and it will not be amiss to 
observe the old-fashioned rule of letting the index always be nearest 
the heart ; the different points with regard to the pulse should then 
be ascertained, each by a distinct and separate act of attention. The 
point first to be noted is the frequency, the number of beats per min- 
ute, the regularity or irregularity of the beats as to time, and their 
equality or inequality in force. This is simple and easy. 

" We should naturally wish, in the next place, to estimate the 
force or strength of the pulse, but considerations which modify the 
idea derived from the impression made on the fingers may first be 
conveniently discussed. It will be well, therefore, after counting 
the pulse to give attention to the size of the artery. This varies 
greatly in different individuals, and may differ in the two wrists of 
the same person. It varies, again, greatly according as the muscular 
coat is relaxed or contracted. We have, then, as a preliminary to 
any further inference, to distinguish between congenital differences 
in the diameter of the vessels and variations induced by physiolog- 
ical or pathological influences. Now, a large artery will communi- 
cate a more perceptible impression to the fingers placed lightly upon 
it than a small one, and the beat will seem more forcible. On the 
other hand, the pulse-wave in a large artery can usually be arrested 
more readily by pressure, and the pulse is more compressible ; one 
mode of examination thus controls or corrects the other. When the 
artery is small, and especially when it is rendered small by contrac- 
tion of its muscular coat, there appears to be little pulsation in it, 
and the pulse may easily be set down as weak ; but let an attempt 



794 TEE PRACTICE OF MEDICINE. 

be made to obliterate it by compression, and it often seems as if the 
pulse grew stronger as the pressure on the vessel increased. An 
important point to be investigated is the degree of constant pressure 
prevailing in the arteries. The constant intra-arterial pressure or 
pulse tension is manifested by the degree of fulness of the artery 
between the beats. To determine this, the artery must first be rolled 
transversely under the three fingers, or the attempt must be made 
to do so. In a pulse of average tension the vessel only stands out, 
so as to be felt distinctly, during the actual beat, and subsides grad- 
ually or rapidly in the interval ; it cannot, therefore, be rolled by 
the fingers at all periods, though it may generally be distinguished 
with care between the beats, especially when the skin is thin and 
flexible. In a pulse of low tension the vessel can scarcely be said 
to be felt as such at all ; it starts up with the beat, and is at once 
lost again when the brief wave has passed. In a pulse of high ten- 
sion, on the other hand, the artery stands out among the structures 
of the wrist like another tendon, and can be rolled like a cord under 
the fingers, and followed for some distance up the forearm. While 
the vessel is thus being rolled about, the pulsation in it may scarcely 
make itself felt, and the artery can often be seen distinctly, if the 
skin is thin, projecting on the surface, without any appearance of 
pulsation, except where it is thrown into curves. Pressure, however, 
brings out the pulsation and develops its force. 

The character of the beat is another matter for study ; and brief 
as is the period occupied by it, each pulse-wave presents a rise, du- 
ration, and fall. It may strike the finger suddenly or lift it delib- 
erately ; the distension of the artery may be momentary only, or it 
may persist for a time ; the fall of pressure finally may be abrupt or 
gradual. For the most part, a sudden rise, brief duration, and ab- 
rupt fall go together, and constitute the short pulse of large arteries 
and low tension ; while a gradual rise, persistent fullness, and slow 
decline are usually associated, and give the long pulse of contracted 
arteries and high tension. Exceptions, however, occur, and they 
are often of great significance. There may be a large vessel and 
sudden pulse, when the tension is relatively high, in cases of dilata- 
tion of the left ventricle ; and a small artery, slowly and feebly filled, 
in extreme low tension with cardiac weakness. We are now prepared 
to estimate the strength of the pulse. Three fingers are placed on 
the vessel, as i= supposed to be the case from first to last. With that 



DISEASES OF THE HEART, 795 

nearest to the heart, pressure is made till the wave is arrested, so as 
not to be felt by the other fingers, or, if necessary, two fingers are 
employed to distinguish the pulsation. In this way, by the degree of 
pressure required, and by varying the pressure with one, two, or all 
three fingers, an idea is obtained of the force with which the heart 
is propelling the blood onwards. 

I have spoken of the manoeuvre of rolling the vessel transversely 
under the fingers as a means of estimating the pressure and tension 
by which it is maintained in the cylindrical form. Another manoeu- 
vre, by which the state of the coats of the artery is ascertained, is to 
carry the skin along it longitudinally, with varying pressure ; curves 
in its course and bulging in its walls are thus detected, and when 
the compression is carried so far as to exclude the blood, any ine- 
qualities of thickness and density in the coats which may exist are 
felt, sometimes mere thickening and hardening, at others actual 
patches of rigidity and calcareous deposit ; or the entire vessel may 
be found to have a thick, leathery, inelastic feel, or may be con- 
verted into an irregular, hard, calcareous tube, or may feel like a 
string of beads under the finger. 

" Here a word must be said as to the terminology to be employed 
in speaking of the pulse ; the words quick and slow are capable of 
two applications : either to the rate at which the beats follow each 
other, or to the character of the individual beats. This ambiguity 
may be avoided by the use of frequent and infrequent to indicate 
the number of beats, and of long and short to describe the individual 
pulsations, as was the practice with old writers on the pulse. A pul- 
sation is long when the increased pressure due to the cardiac systole 
can be felt by the fingers to last for an appreciable time ; it is short 
when the pressure is quickly gone. The words strong and weak are 
even more vague when applied to the pulse than the words quick 
and slow ; they are apt to be used at one time in reference to the 
mean pressure in the artery, at another in reference to the pulse- 
wave, the significance being totally different in the two cases. The 
terms compressible and incompressible are scarcely more definite 
unless it is stated whether they apply to the artery between the beats 
or to the pulsations themselves. We must have terms which are 
incapable of this indiscriminate application. We might speak of 
the pulse being hard or firm without much risk of this being under- 
stood to apply otherwise than to the general feel of the artery, and 



796 



THE PRACTICE OF MEDICINE. 



therefore to the state of fulness and degree of resistance to press- 
ure in the intervals between the beats. It would scarcely, however, 
be accurate to say that the pulse was firm, although this would be 
justified by the example of the ancients, who were very exact in their 
employment of terms, and it is well to avoid as far as possible all 
latitude of expression. If it is well understood that by tension we 
mean pressure, and that this is estimated by the fulness of the 
artery and the degree of resistance to pressure between the beats, 
there can be no better term for conveying an idea of this mean press- 
ure than high, moderate, or low tension. We may then describe the 
beat as vehement or sluggish, or as forcible or weak, always bearing 
in mind that the wave may be abrupt or gradual. The standard or 
typical pulse of the adult male may now be described. It will have 
a frequency of seventy-two beats per minute, will be perfectly regu- 
lar in time, and the beats will be of equal force. The artery will 
be of medium size ; with care it can be distinguished among the sur- 
rounding structures between the beats, but it yields to pressure, does 
not give the idea of a cord, and cannot be rolled as such under the 
fingers ; it is flattened by moderate force, and does not then feel 
thick or hard. The individual pulse-waves reach the finger nearest 
the heart with a definite stroke, which can scarcely be described as 
sudden, still less as sharp ; they have sufficient vehemence to be felt 
by all three fingers, unless decided pressure is made on the vessel, 
but they can be arrested without difficulty by one finger, the beat 
then feeling both more sudden and more vehement. The wave, or 
expansion, or distension of the artery does not instantly drop, but 
subsides gently and without perceptible dicrotism. 

" The following is a tabular view of the variations from the nor- 
mal pulse referred to the heart and arteries respectively : 

Frequency. f Frequent. 

Infrequent. 

Rhythm. Pulse J Irre g ul . ar - 

J Intermittent. 
Force. Excessive. 

Defective. 



Heart. 



Arteries. 



Relaxed. 
Contracted. 



r Large. 

Short. 

Low-tension. 

Small. 

Long. 
i High-tension. 



DISEASES OF THE HEART. 797 

" This classification of the deviations from the normal pulse will 
serve as a guide in their consideration, but it would be impossible, 
even if it were convenient, to discuss quite separately and independ- 
ently the variations due to the heart and those due to the vessels. 
The heart and arteries are, after all, only parts of the same system 
correlated throughout by mutual interdependence and by the vaso- 
motor nerves, and abnormal frequency of the heart's action is usu- 
ally associated with relaxation of the peripheral vessels, and contracted 
arteries with deliberate heart-beats. Some of the more common com- 
binations may, indeed, with advantage, be enumerated. Frequency 
and force of the heart's action, with dilated arteries, give the pulse 
of sthenic fever, and of violent but not excessive muscular exertion, 
which is frequent, sudden, vehement, large, short, and dicrotus. 

Frequency and force, with arteries moderately contracted, give 
the pulse of excitement, of an early stage of effort, and of the pyr- 
exia attending some forms of inflammation, with extreme contraction 
of the arteries, the pulse of peritonitis, and of severe rigor. Fre- 
quency, with deficient force on the part of the heart and relaxed ar- 
teries, gives the pulse of asthenic fever and of exhaustion, which, 
while frequent and sudden and short, has no vehemence ; the dicrotic 
wave is sometimes so marked that it is almost as distinct as the pri- 
mary wave. The artery is large, except when the cardiac weakness 
is extreme. 

A normal and slightly slowed heart-rate, with diminished force 
and relaxed arteries, gives the pulse of fatigue and of convalescence 
from acute disease, both force of heart and arterial tone increasing 
as convalescence advances. Normal or slightly diminished frequency 
and increased force of the cardiac systole, with contraction of the 
arterioles, constitutes the so-called renal pulse, of which much will 
be said hereafter, but it is common to kidney disease and to a vari- 
ety of other conditions with which high tension of the pulse is asso- 
ciated." 

The pulse of infants presents an interesting study. Dr. Edwards, 
in the "Medical and Surgical Reporter," says that " the most 
marked characteristic of the infant's pulse is irregularity, which 
occurs whether the child is asleep or awake, at rest or in active move- 
ment. Conditions which will hardly perceptibly affect the pulse of 
the adult will derange the rhythm of the infant's pulse to a marked 



798 THE PRACTICE OF MEDICINE. 

degree ; disorders of digestion, so common in infancy, show marked 
effect upon the pulse rhythm. Irregularity is also seen during con- 
stipation, or diarrhoea, and is associated with intestinal worms and 
with dentition. An important, and as yet unrecorded, difference 
between the infant's pulse and that of the adult is the fact that in 
the former there is an entire absence of dicrotism, and it does not 
appear until the child has reached the tenth to the fourteenth year; 
the infant's pulse has not the same recoil as the adult's ; it has fur- 
thermore been demonstrated that blood-pressure in the young is very 
low, and that dicrotism in the adult pulse is produced by conditions 
that do not exist in the infant. It is also well known, since Marey 
demonstrated the fact, that the longer the vessel the greater the 
dicrotism. Infants present great variability in the size of their 
arteries. On the other hand, the arterial system may be unduly 
small. The character of the pulse in infants is difficult to describe ; 
it yields readily to the finger of the observer, is small, irregular, and 
does not present any marked difference between systole and diastole. 
One observer aptly remarks that the pulse of the infant is deprived 
of sense, rules, or proportion. It is affected by the most trivial 
departures from health. Even a slight accumulation of flatus, for 
instance, will so alter the pulse that judging from it alone, one could 
not avoid concluding that the little patient was the subject of a grave 
disease. While irregularity in rhythm may be considered one of the 
normal features of the pulse, it is not so, however, with persistent 
frequency, which is always a manifestation of cardiac overstrain, no 
matter how young the child may be ; it also occurs in association with 
anaemia, leukaemia, and malarial intoxication in babes. The frequent 
action may be constant or paroxysmal in its appearance. Occasion- 
ally in infants we meet with exactly the opposite condition, namely, 
infrequent pulse, which is usually congenital, although the author 
has several times observed an infrequent pulse associated with the 
jaundice that is common during the early months of life, and also 
with renal disorders. The congenital cases are liable to present also 
evidences of cerebral disturbances, great mental excitement, or epi- 
leptiform attacks." 

It is said by the best authorities that the pulse of infants at birth 
varies from 130 to 150 per minute, and decreases in rate with every 
year of life. At five years it may be normal at 120 ; at ten years, 



DISEASES OF THE HEART. 799 

100 ; at fifteen, 75 to 85. A female infant's pulse is a few beats 
more per minute than the male. 

My experience is that an intermittent pulse in infants who have 
no heart disease almost invariably points toward some form of cere- 
bral disease, either basilar meningitis, or tubercular meningitis. 



THE IRREGULAR PULSE. 

Arythmia, when applied to irregular pulse, means that the pulse- 
beats follow each other at irregular intervals and are unequal in 
force. An irregular pulse varies greatly in degree, and it is proba- 
ble that each variety may have a different significance. When the 
irregularity is extreme there is a rapid succession of small, weak 
beats, followed by a few large and distinct ; or, there may be no 
method whatever in the irregularity, no two beats being alike either 
in time or force. Irregularity of the pulse may be either habitual 
or occasional. When occasional it may be induced by reflex dis- 
turbance of the cardiac rhythm, gastric irritation, flatulence, and 
other functional disturbance of the abdominal viscera. In flatulence, 
dyspepsia, hysteria, or typhoid fever, if there is distension of the 
abdomen, irregularity of the heart's action is common. Tobacco 
oftener causes irregularity than intermittence. So, also, with tea and 
coffee. A kind of quivering palpitation is usually caused by tea and 
tobacco. Green tea, and the best tobacco strong in nicotine, oftener 
causes irregularity than black tea or mild cigars. It should be re- 
membered that irregularity of the pulse may be caused by diseases 
of the respiratory organs. Obstruction of the respiratory passages 
by bronchitis, emphysema, phthisis, and pneumonia may all induce 
irregularity. Habitual irregularity of the pulse is a common result 
of mitral insufficiency and is the characteristic pulse of this form of 
valvular disease. "It is so frequent in mitral regurgitation, and so 
rare in other forms of valvular disease, that it can scarcely be put 
down to any secondary alternations of the cavities or walls of the 
heart." (Broadbent.) 

When extreme and habitual irregularity of the pulse cannot be 
traced to any other cause, we must attribute it to the nervous system. 
As in habitual intermittence, the general health, vigor, and endurance 



800 THE PRACTICE OF MEDICINE. 

of the persons may be excellent. They may attain old age without 
showing any other sign of cardiac trouble. 

Generally I consider irregularity more important than intermit- 
tence. In children whose hearts are sound it may arise from worms 
in the intestines, but often it is the first and ominous symptom of 
tubercular meningitis or basilar meningitis. 

Allen (" Encyc. Mat. Med.") gives more than one hundred drugs 
causing irregular pulse. Snader (" Repertory in Hale's Diseases of 
the Heart") gives fifty, and this is the most trustworthy. 

Treatment. — It need not be repeated that the cause of the irreg- 
ularity must be ascertained before any medicine can be properly 
selected. If it be due to mitral insufficiency, it means that compen- 
sation of the auricular muscles should be favored by the primarily 
homeopathic remedies, aconite, bryonia, kali cyanuretum, gelsemium, 
veratrum album, veratrum viride, colchicum, arsenic, etc., or by 
those secondarily indicated (heart tonics), apocynum cann., digitalis, 
adonis, strophanthus, cactus, anhalonium, prunus virginiana, spar- 
teine, etc. If worms be the cause, santonine, salol, cina, silica, teu- 
crium, kousso, pumpkin seeds, naphthaline, kameela, granatum, etc., 
are indicated. 

Sexual neuraesthenia is a potent cause of irregular pulse and 
should be treated by phosphate of strychnine 3x, cactus lx or mother 
tincture, sabal lx or mother tincture. When the arythmia arises 
from uterine or ovarian irritation, bromide of camphor, bromide of 
strontium, or any other bromide will usually control it, but in special 
cases lilium, sepia, Scutellaria, palladium, murex, cimicifuga, or vi- 
burnum may be indicated. 

In purely neurotic cases special medicines in affinity with the 
nervous system must be selected. I have had the best results from 
zinc, phosphate of iron, arsenic, aurum, argentum, and the bromides. 

I have known an irregular pulse, which had persisted for weeks, 
disappear under lycopodium, asafcetida, and salol, given for flatu- 
lence. A change in the diet to foods which will not cause flat- 
ulence is also necessary. I have also known extreme irregularity of 
the heart's action to cease when the bowels were unloaded by a good 
thorough laxative. No strictly homeopathic medicine will thoroughly 
empty the intestines and clear out the ptomaines which poison the 
blood and nervous system as well as the heart. 



DISEASES OF THE HEART. 801 



THE INTERMITTENT PULSE. 

By intermittent pulse is meant the omission of a beat from time 
to time. The rhythm of the pulse will generally vary with that of 
the heart, but not always, for a heart may beat regularly while the 
pulse intermits. The explanation is that when the pulse intermits, 
it does so because the contraction of the heart during the intermis- 
sion is not complete enough to send the pulse wave to the radial 
artery. Dr. Broadbent says this variety of pulse is the least explain- 
able of any, and is not, so far as he is aware, producible by experi- 
ments. There are several drugs, however, which cause intermittent 
pulse. When found in patients it is generally due to some perverted 
nervous influence. It is very rarely due to any structural disease of 
the heart. The intermission may happen at regular and definite 
periods, every six or up to twenty beats, or the number of interven- 
ing pulsations may vary. The interval produced by the missing beat 
is not usually quite equal to two beats, and the succeeding beat feels 
stronger from the pressure in the arteries having run down. The 
heart-beat, again, which immediately follows the intermission is 
usually more powerful than the others. The intermittent pulse may 
be constitutional, constant, and due to congenital causes. This con- 
stant habitual pulse appears to have no significance either in relation 
to the heart, or to the nervous system, or to the vital power gener- 
ally. It is common in men who retain vigorous health to a good old 
age, and Broadbent knew of a case at the age of eighty in whom it 
had existed for forty years. 

It may occur occasionally from some disturbing cause, as flatu- 
lence, indigestion, or the abuse of tea, coffee, tobacco. It is common 
in chronic gout, neursesthenia, hypochondria, congestion of the liver 
or jaundice. 

It is among the signs of fatty degeneration of the heart. If it is 
caused by that condition, a brisk walk for a minute or so will aggra- 
vate the intermittence ; if not, the exercise will regulate the pulse. 
If the intermittence comes on when sitting or lying, and is removed 
by exercise, it is probably due to hepatic disorders. 

If caused by tea, coffee, or tobacco, it will disappear in a few 
days after ceasing to use them. If the intermittence is purely neu- 
rotic, exercise, excitement, and fever will regulate the pulse. It will 

50 



802 THE PRACTICE OF MEDICINE. 

become regular during the administration of ether, and sometimes 
during chloroform. 1 have known many cases when the patient was 
not conscious of the intermittency. It is more likely to be felt when 
it is symptomatic or functional than when it is habitual. There may 
be felt a vague sense of discomfort in the cardiac region, or a sud- 
den sinking feeling in the epigastrium during the intermission, or 
the " bump " of the stronger beat after the intermission may be felt. 
If we auscultate the heart we may find that during the intermission 
it does not actually cease to beat, but an imperfect contraction takes 
place, which is felt as a kind of vibration. In some cases, however, 
no sound is heard, and the heart evidently stands still. Broadbent 
says intermittence is worse after meals. My experience is to the 
contrary, for my patients are worse before meals and eating, and a 
little wine or liquor regulates the pulse. 

Treatment. — If the intermittent pulse is hereditary, or habitual, 
or has lasted several years, and the general health is good, with nor- 
mal heart-sound, no treatment is necessary, and the use of medicines 
in large doses to regulate the heart will be injurious. 

When caused by tea, coffee, or tobacco, if a suspension of these 
stimulants does not arrest it, digitalis and strychnine, or ignatia, in 
small doses, will bring about regularity. If due to indigestion, treat 
that condition. An intermittent pulse is an early symptom of bas- 
ilar or tubercular meningitis, and medicines for that condition and 
not for the heart should be used. 

Allen, in his " Index of Symptoms," gives eighty-eight medicines 
as causing intermittent pulse. Now it is not to be supposed that all 
of them could by any possibility cause such a condition. When we 
consider that the majority of provers did not know the difference 
between an intermittent and an irregular pulse we see how unreli- 
able this symptom is in our pathogenesis. From the eighty-eight 
medicines I would select a few as most useful; namely, aconite, 
apocynum cann., digitalis, ferrum, glonoine, nux vomica, oleander, 
strychnine, veratrum album, and veratrum viride. To these may be 
added adonis, strophanthus, convallaria, cactus, spartiene, or coron- 
illa which we know from clinical experience will regulate an inter- 
mittent heart. If we find the intermittent pulse is caused by hepatic 
disorders, then mercurius, euonymin, chelidonium, carduus, agari- 
cus, ammon. mur., podophyllum, iris ver., chionanthus, and lyco- 



DISEASES OF THE HEART. 803 

podium will be useful. If due to meningeal irritation, gelsemium, 
belladonna, agaricus, hyoscyanius, or strammonium. If there is 
high arterial tension, use glonoine, veratrum viride, or kali iod. If 
due to a weak heart from fatty degeneration or dilatation, phosphorus, 
strychnine, and digitalis are the three chief remedies. 



DISEASES OE THE VEINS. 
I. — PHLEBITIS. 

" Causation and Morbid Anatomy. — Inflammation of a vein is 
generally due either to the formation of a clot within it, in which 
case the process commences at the inner surface and travels outward, 
or to the involvement of the vein in inflammatory processes which 
are going on round about it, in which case its walls are invaded from 
without inwards. Phlebitis, indeed, is almost always secondary. 
Exceptions to this rule are furnished by inflammation of the uterine 
veins after parturition, and by the comparatively rare thickening 
of the inner coat of veins which correspond to the much more fre- 
quent thickening of the inner coat of arteries issuing in athero- 
matous and calcareous degenerations. The presence of clots may 
be regarded as an essential accompaniment to all forms of phlebitis, 
with the exception of the chronic form last adverted to. Inflam- 
mation of veins is characterized by thickening of their walls, con- 
nected with proliferation of the protoplasmic elements of their sev- 
eral laininse. The latter process is generally especially active in the 
outer coat, which not infrequently acquires considerable thickness 
and blends with the surrounding similarly affected connective tis- 
sues : and scattered abscesses are apt to appear here and there in its 
course. The inner coat tends to become rough, and even to give 
rise to granulations. The contained clot, whether it be formed pri- 
marily or secondarily, soon fills the channel of the vein and adheres 
more or less firmly to its communication with a trunk vein, below 
into the tributary branches. The further changes which such clots 
undergo will be considered under the head of Thrombosis. 

The symptoms of venous inflammation are, if the vein be within 
reach of direct observation, pain and tenderness in its course, with 
cylindrical thickening and hardening, and sometimes superficial red- 



804 THE PRACTICE OF MEDICINE. 

ness. Abscesses in the course of the vessel, communicating or not 
with its interior, are not infrequent. There is necessarily febrile 
disturbance. The remote effects of phlebitis are on the whole much 
more important than the local effects. They embrace, on the one 
hand, those due to venous obstruction, dilatation of the distal veins, 
congestion, and anasarca ; on the other, those dependent on the dis- 
charge of fragments of a thrombus, or of inflammatory or other hurt- 
ful matters into the circulating blood." (Bristowe.) 

Treatment. — If there is a temperature over 100° P., with hard- 
ness and tenderness of the veins — aconite lx, and glonoine 2c, 
internally. An efficient and soothing external application is a dis- 
tilled extract of hamamelis, with tincture of arnica, eight parts of 
the former to one of the latter. Cloths or lint, kept constantly wet 
with this mixture, should be applied and renewed as often as they 
become dry. This treatment seems to favor the absorption of the 
clots and remove the thickening of the coats of the vessels. Bella- 
donna is sometimes useful when the phlebitis assumes an oedematous 
erysipelatous character. Apis has also been of value. 



THROMBOSIS AND EMBOLISM. 

Definition. — " The term thrombosis has been conveniently applied 
to the coagulation of blood during life in the heart, arteries, or veins, 
and includes within its meaning nearly all those cases which were 
formerly regarded as phlebitic. The term embolism has been intro- 
duced to designate those cases in which an artery or vein gets plugged 
by the impaction in it of a clot or solid mass conveyed to it from a 
distance by the blood-stream. The morbid phenomena and symp- 
toms which thrombosis and embolism induces are referrable partly 
to local inflammation, but principally to artetial or venous obstruc- 
tion." (Bristowe.) 

THROMBOSIS OF VEINS. 

" In the systemic veins the coagulation of blood during life is 
common enough. When the venous circulation is simply enfeebled, 
as in the later stages of heart-disease, and towards the close of 
phthisis, carcinoma, and other chronic wasting affections, venous 
thrombosis is of frequent occurrence. It then takes place more par- 



DISEASES OF THE HEART. 805 

ticularly in the trunk veins of the lower extremities, and in those of 
the pelvis or at its brim. So, again, when some impediment exists 
to the passage of blood along a vein, the distal portion of the vessel, 
and in a greater or less degree its tributary branches, fill with clot. 
When veins are involved in inflammation which is taking place 
round them, this, as has been pointed out, tends soon to pervade the 
entire thickness of the walls, and then to induce coagulation of the 
blood within them, and their complete obstruction, and occasionally, 
indeed, by perforation of a vein or some other process, pus or other 
inflammatory products find their way into its interior or into the 
substance of the thrombus. Thrombosis, secondarily to inflamma- 
tion, is common in erysipelas, diffuse cellular inflammation, carbun- 
cle, and the like ; in puerperal pelvic cellulitis ; in inflammation in- 
volving the cancellous structure of bones, or the walls of the partu- 
rient uterus ; and in the venous sinuses of the interior of the skull 
in connection with disease of the internal ear. 

" Whenever a thrombus forms or an embolus becomes fixed, in- 
flammation of the implicated vascular walls, if it did not previously 
exist, speedily ensues ; and hence pain and tenderness soon mark the 
course of the vessel if it be within reach of investigation, and febrile 
disturbances generally arise. In either case complete obstruction to 
the passage of blood through the affected vessel takes place very 
soon if not quite suddenly. 

" The results of venous thrombosis are stagnation of blood in the 
tributary veins with dilatation, soon followed by oedema and com- 
pensatory enlargement of the anastomotic veins. These conditions 
are not secondary to thrombosis only, but attend all cases in which 
veins from whatever cause are obstructed. The consequences of ar- 
terial thrombosis or embolism, on the other hand, are impairment of 
nutrition of the region which the artery supplies, and, following on 
this, congestion, hemorrhage, inflammation, degeneration, or gan- 
grene, together with special symptoms due to the organ or part whose 
integrity is compromised. Similar phenomena necessarily ensue 
upon all forms of arterial obstruction, no matter how they are pro- 
duced. The special effects of thrombosis and embolism will, for the 
most part, be best discussed in connection with the other morbid 
conditions of the several organs in which they occur. There are two 
or three cases, however, which may be most conveniently considered 



806 THE PRACTICE OF MEDICINE. 

now. They are phlegmasia alba dolens, thrombosis and embolism 
of the heart and pulmonary artery, obstruction of the larger arteries 
of the limbs, and multiple embolism of the smaller systemic arteries. 

" Phlegmasia alba dolens. — This term is generally applied to the 
painful and oedematous condition of leg which often follows upon 
parturition. An almost exactly similar condition may, however, 
occur independently of parturition, and even in males, and is not 
infrequently developed in the course of phthisis and carcinoma. 
The arms also may be affected in like manner as the lower extremi- 
ties. Phlegmasia alba dolens is due to thrombosis of the trunk veins 
of the limbs, or of the larger veins to which these converge, which 
becomes converted into painful rigid cords. When it follows par- 
turition it generally begins from a week to a month after that event, 
and almost always in the left lower limb. And even if the right 
become affected it is usually affected in company with the left but 
at a later period. The commencement of this disease is generally 
sudden, and indicated by the concurrence of diffused pain through- 
out the affected member, and oedema. The pain varies in character 
and intensity, and is generally attended with soreness or tenderness, 
sometimes with distinct hyperesthesia, sometimes with loss of sen- 
sation ; and not infrequently the patient is unable, either from pain 
or from loss of power, to move the limb or any of its parts. The 
oedema gradually increases until the member gets large and smooth, 
and of a peculiar pale, waxy aspect ; it does not generally pit dis- 
tinctly on pressure, and often presents a mottled, retiform character, 
owing to the rupture, as in pregnancy, of the deeper layers of the 
cutis. There is not, as a rule, any manifest change of temperature 
in the affected limb ; but general febrile disturbance is usually pres- 
ent. If there be no serious complication, the patient probably recov- 
ers at the end of three or four weeks. For the most part, however, 
the veins primarily obstructed remain impervious ; and sometimes 
there is permanence of oedema." (Bristowe.) 

Treatment. — One of the most complete articles ever written on 
the etiology and pathology of phlegmasia alba dolens can be found 
in Leavitt's " Obstetrics " and was written by Dr. L. L. Danforth 
and Dr. C. G. Higbee. From the researches of various investigat- 
ors, there would seem to be three varieties of this disease : (1) a true 
phlebitis from traumatism, (2) thrombosis in the veins of the leg, 



DISEASES OF THE HEART. 807 

and (3) septic infection. Sometimes two or all of these conditions 
may be present to complicate the case. 

The prophylaxis of this affection consists in strict asepsis and 
antisepsis during and after labor ; and attention to the general health 
of the patient. As soon as pain, heat, and swelling appear the leg 
should be closely enveloped in compresses composed of distilled 
extract of hamamelis one quart and tincture of arnica one ounce. 
Over the compress place a thick covering of cotton batting. This 
is all the local treatment necessary. The leg should not be rubbed 
while it is hard. Wait until it begins to grow soft, then rub gently 
twice a day with oil of arnica eight ounces, spirits of ammonia half 
an ounce. In the septic variety half an ounce of oil of turpentine, 
ichthiol, or lysol can be added to the above mixture. Judging from 
the excellent effect of ichthiol in other affections of a similar nature 
ichthiol may be of great value in all varieties of this disease. A ten 
per cent solution can be applied. 

Internally for the fever, aconite, baptisia, or veratrum viride. 
I 1 or the pain, phenacetin, or piscidia in suitable doses. Arnica, 
hamamelis, apis, and belladonna, will be indicated in many cases. 

Constipation should not be allowed, and a good action of the kid- 
neys should be obtained. 



2 VARIX (Dilatation of the Veins.) 

Causation. — Dilatation of veins is much more common than 
that of arteries, but its causes are a good deal more obscure. It 
occurs, no doubt generally, in obstructive diseases of the right side 
of the heart, and when a vein is obstructed, throughout the venous 
system which is tributary to it, as well as in those collateral veins 
which take on, or divide between them, the duties of defaulting ves- 
sel. But in a large number of cases veins get dilated and varicose 
independently of all obstruction, independently of overwork, and 
independently also of obvious degeneration or weakening of the walls. 

Morbid Anatomy. — When veins dilate they become at the same 
time elongated and consequently tortuous. The dilatation usually 
commences, and is always most marked, immediately above the 
valves ; and the affected veins assume, therefore, an irregular moni- 
liform aspect. The walls, for the most part, thicken considerably, 



808 THE PRACTICE OF MEDICINE. 

although presenting occasional attenuations, especially over the con- 
vexities of the dilated portions. The thickening is principally due 
to hypertrophy of the middle coat, the attenuation to its atrophy or 
disappearance. With the progress of dilatation the valves become 
inefficient, and often shrivel up ; calcareous plates not unfrequently 
form in the middle coat ; the connective tissues around gets thick- 
ened and indurated, and blended with the outer coat of the veins ; 
phlebolites are often developed into the pouch-like protrusions of 
ulceration from without or by laceration. 

Dilatation may occur either in veins of medium or large size, or 
in those which are ordinarily mere capillary tubes. The former oc- 
currence is exemplified by the ordinary varicose veins of the lower 
extremities, and by varicocele, the latter by the tuft-like groups so 
common in the lower limbs of pregnant women. Dilatation and 
varicosity of veins rarely require treatment at the hands of the phy- 
sician. For him they serve mainly as important aids to diagnosis. 
Varicose veins in the lower extremities, varicocele, and hemorrhoids 
are surgical disorders. Dilated or varicose veins of 'internal organs 
no doubt occur, and aid in the production of functional disturbances ; 
they may even rupture and cause death by hemorrhage. We have 
witnessed this accident in the case of varicose veins of the oesopha- 
gus. But their presence can rarely, if ever, be recognized during 
life. The importance of the dilatation of certain groups of superfi- 
cial veins in enabling us to judge of the seat and character of inter- 
nal diseases involving the obstruction of deep-seated veins is obvious." 
(Bristowe.) 

In direct opposition to the dictum of the above quoted author, 
Burnett, in his " Diseases of the Veins," says : " Atonic, dilated 
veins may, in many instances, be made to shrink to their original 
size by the proper use of medicines administered internally — in other 
words, varicosis, hemorrhoids, varicocele, and varices are amenable 
to drug treatment, and therefore, surgery, in this department of dis- 
eases of the veins is to be superseded by medicines." 

In another place he says : " General varicosis eludes the surgeon 
entirely, for surgery must necessarily be local." He hits the truth, 
also, when he says " a merely surgical cure is no real cure at all, and 
in its very nature cannot be radical — better than nothing, no doubt ■ 



DISEASES OF THE HEART. 809 

and often nearly as good as a cure, still, not a healing in its true 
sense." 

Even E. H. Pratt's method of extirpating the whole " pile-bear- 
ing inch," will not cure permanently when the dilated veins are due 
to causes within the liver or portal system. 

Burnett's assertion is borne out by thousands of homeopathic 
physicians, and also by many eminent practitioners of the old school 
— such men as Tripier of France, and N. S. Davis of this country. 
In my experience and studies of our therapeutics the real remedies 
for diseases of the veins of a primary origin appear to be hamamelis, 
collinsonia, aurum, arnica, aloe, ferrum, baryta, pulsatilla, carduus, 
aesculus, hydrastis, nitric and muriatic acid, nux vomica, and sulphur. 

When varices are due to disease of the liver, carduus, chelido- 
nium, mercury, euonymin, podophyllin, chionanthus, nitro-muriatic 
acid, aesculus, and agaricus are indicated. When they are due to a 
feeble heart — causing venous stasis — cactus, collinsonia, digitalis, 
strophanthus, convallaria, viscum album, and nux vomica or strych- 
nine will be found most efficient. When varices of the legs and 
vulva occur in pregnant women, it is due to pressure preventing the 
return of venous blood. Medicines will do little good unless the ab- 
domen be suspended by an abdominal bandage ; then hamamelis, 
collinsonia, and arnica may be of great value. 

Varicocele, when not of too long standing, can be cured by col- 
linsonia. Burnett reports a remarkable case of varicocele, with gen- 
eral varicosis and varicose veins, which greatly improved under the 
long- continued use of ferrum phos. 6. Incidentally he says " ferrum 
phos. is most useful in the varicoses of the old ; fluoric acid in the 
young." He reports a case of varicocele which was nearly cured by 
fluoric acid 6. 

I once reported a case of varicose veins of the legs cured by ham- 
amelis. When I began to treat the case I prescribed in doses of a 
few drops of the tincture three times a day. But little improvement 
was noticed after several weeks. The patient was a man who had 
a history of constitutional varicosis inherited from his mother. I 
was about to abandon hamamelis when I saw in an old school jour- 
nal a cure of an extreme case, by teaspoonful doses of the fluid 
extract. Feeling it my duty to test it, I prescribed that dose three 



810 



THE PRACTICE OF MEDICINE. 



times a day ; to my gratification and surprise the condition began 
to improve in less than a week, and in three weeks hardly an 
enlarged vein could be seen. Neither during the time the patient 
was taking these large doses, nor after, did there appear a single 
pathogenetic symptom ; on the contrary his digestion and general 
health improved all the time. This should teach everyone, as it 
did myself, that we too often have an unfounded fear of material 
doses. 

I cannot omit to quote in this place the surprising curative effects 
of carduus, as reported by Dr. A. Tripier of France, and which I have 
often verified in my own practice. In the " Bulletin General de 
Therapeutique," he writes of visceral varices : 

" Varices of the superficial veins of the limbs or the trunk are 
easily perceived. In the deeper veins of the members their diag- 
nosis is more obscure, and we know that they exist and give rise to 
painful oedemas which have thus far been treated by the merely pal- 
liative measure of compression. Other localization of varices we 
recognize as hemorrhoids and varicocele. I was once satisfied with 
these summary notions of varix. Clinical observation, however, led 
me to ask if the veins of all the organs might not be exposed to this 
trouble, and if certain obscure objective phenomena might not be 
properly referred to such congestions. In the spring of 1867 I was 
consulted by a friend who, while in excellent health, had been at- 
tacked by hematuria, with weight and painful tension of the pelvis. 
There was not much loss of blood, and clear urine was often promptly 
passed after a free injection of liquids. The patient's doctors had 
prescribed astringents, ending with perchloride of iron. But these 
caused an aggravation of the symptoms and I asked myself if a vari- 
cose condition of the rectum, though it did not there cause hemor- 
rhage, might not have extended to the lower portion of the bladder 
and have brought on the symptom. In this belief I prescribed tinc- 
ture of carduus marianus twenty-five drops twice daily in a tumbler 
of water. There was an immediate amelioration of perineal tenes- 
mus, and the hematuria ceased in a few days. The trouble appeared 
once again during the lifetime of the patient (he died of typhus five 
years after I first treated him), and the immediate use of carduus 
marianus arrested the hematuria from the start. My choice of car- 



DISEASES OF THE HEART. 811 

dims marianus (chardon Marie) arose from my observing the use 
made of it by Dr. Worms. Since then, my gynecological practice 
has offered a large number of examples of these painful cedemas 
arising from varicose stasis. They are often found in the urethra 
or meatus of women — alone or in conjunction with anal hemorrhoids 
— and, though rarely causing sanguineous discharge, gives rise to 
very painful dysuria. In some cases the pain is extreme and con- 
tinuous in paroxysms for several days. For all of these patients I 
prescribe, first, twenty drops of the tincture of carduus marianus in 
a tumbler of water night and morning. In cases in which this is 
not sufficient, I practice rapid dilatation of the urethra with Blanch- 
et's " auri-bivalve speculum," whose plates I elongate to seven centi- 
meters. One dilatation is usually sufficient; sometimes a second, 
six months afterward, is needed ; in one case which I have lost sight 
of, two dilatations were sufficient ; in a certain number of cases I 
have kept track of, the cure remained permanent for ten or twelve 
years." 

The veins may become sclerotic. According to Osier " sclerosis 
of the veins — phlebo-sclerosis — is not at all an uncommon accom- 
paniment of arterio-sclerosis, and is a condition to which of late a 
good deal of attention has been paid. It is seen in conditions of 
heightened blood-pressure, as in the portal system in cirrhosis of the 
liver and in the pulmonary veins in mitral stenosis. The affected 
vessels are usually dilated, and the intima shows, as in arteries, a 
compensatory thickening, which is particularly marked in those 
regions in which the media is thinned. The new-formed tissue in 
the endophlebitis may undergo hyaline degeneration, and is some- 
times extensively calcified. In a case of fibroid obliteration of the 
portal vein of long standing, I found the intima of the greatly dilated 
gastric, splenic, and mesenteric extensively calcified. In ordinary dif- 
fuse arterio-sclerosis the veins may also be involved, but rarely to a 
marked degree." 

Treatment. — We have no clinical records upon which to base any 
treatment. Theoretically iodide of barium, iodide of potassium, 
Phytolacca, and phosphorus ought to arrest or modify the degenera- 
tion process. A cure is probably not possible. 



812 THE PRACTICE OF MEDICINE. 



EMBOLISM. 

Causation and Morbid Anatomy. — The sources of emboli are 
mainly venous thrombi, cardiac vegetations, and disintegrating cal- 
careous, atheromatous, or inflamed surfaces. Additional sources are 
softening clots in the interior of the heart, and morbid growths or 
other adventitious bodies. The detached solid mass, whatever its 
nature, is carried along by the blood stream until it reaches a vessel 
which is too small to allow of its further progress. The point at 
which it becomes finally arrested usually corresponds to the bifurca- 
tion of a vessel or to the giving off of a comparatively large branch. 
Here it gets wedged, sometimes blocking up the channel completely, 
but more frequently forming at first a partial impediment only. In 
the latter case the constant pressure from behind tends to drive it 
farther and farther onwards, in consequence of which, or of the grad- 
ual coagulation of blood around it, the vessel becomes at length, as 
in the former case, completely occluded. Subsequently thrombosis 
takes place on both sides of the embolus ; the artery and its distal 
branches get filled with clot which, gradually undergoing changes 
blends on the one hand with the arterial parietes, and on the other 
with the embolus. So that although the embolus may, at first, be 
readily recognized as an independent body, it often becomes undis- 
tinguishable from the thrombus to which its presence has given rise. 

Emboli, taking their origin in the systemic venous system, or 
right side of the heart, necessarily become fixed in the pulmonary 
arteries. Those which originate in the pulmonary veins, left side of 
the heart, or larger systemic arteries, are conveyed to the periphery 
of the systemic arterial circulation. And those, lastly, which are 
yielded by the veins of the chylopoietic viscera find their resting- 
place in the branches of the vena portse. Owing to the infrequency 
of disease of the valves of the right of the heart, embolism involv- 
ing the lungs is almost invariably due to the detachment of venous 
clots or fragments of them. In some cases entire systems of thrombi 
become free, and a complete cast, some inches long, of a venous tree 
may be carried into the pulmonary artery and impacted in a con- 
voluted form within it. More frequently shorter lengths get suc- 
cessively separated and successively lodged in different branches of 
that vessel. It is much more common, however, for venous clots to 



DISEASES OF THE HEART. 813 

crumble, as it were, gradually away ; and for minute fragments to get 
impacted from time to time in the pulmonic arterioles. 

It is rare for thrombosis to take place in the pulmonary veins ; 
and hence embolism is seldom due to this cause. The most common 
source of embolism of the systemic arteries is undoubtedly the 
detachment of the granulations from the diseased aortic or mitral 
valve ; but another frequent cause is the separation of atheromatous 
or calcareous particles, or other detritus, either from the valves or 
inner surface of the heart, or from the large arteries. It is obvious, 
therefore, that embolism of the systemic arteries must in a very large 
proportion of cases depend on valvular disease, and is to be regarded 
as one of the common risks of that affection. 

Emboli from the various sources just indicated are carried along 
the aorta and thence into some of the smaller branches of the sys- 
temic arteries ; whither is in some degree a matter of accident ; but 
there are certain parts, namely, the brain, liver, spleen, and kidneys, 
and, it may be added, the lower extremities, which are specially prone 
to suffer. It is probable, however, that their arteries are not so 
much specially liable to obstruction, as that their obstruction pro- 
duces particularly serious and obvious ill effects. The cerebral 
arteries chiefly liable to occlusion are the middle cerebral branches 
of the internal carotids ; and it is curious that the stoppage gener- 
ally occurs in the middle cerebral of the left side." (Bristowe.) 

Treatment. — There are no specific remedies for embolism. The 
indications are to combat inflammation followed by local oedema. 
The most appropriate medicines are arsenicum, apis, bryonia, phos- 
phorus, hamamelis, rhus tox., and a few others. 



THROMBOSIS OF THE HEART AND ARTERIES. 

" In the heart, after death, the blood which was contained within 
its cavities at the moment of death is generally found coagulated, 
moulded to the form of cavities, and continuous with cylindrical clots 
occupying the trunk veins, and often with similar clots extending 
into the trunk arteries. These clots are sometimes black-currant- 
jelly-like, sometimes partly discolorized ; and the portions prolonged 
into the arteries are usually more or less purely fibrinous, while 



814 THE PRACTICE OF MEDICINE. 

those seated in the veins are usually soft and black. But not unfre- 
quently the clots contained in the heart's cavities, and more espe- 
cially those occupying the ventricles, are almost entirely fibrinous, 
opaque, and buff- colored, close in texture, and even indistinctly lam- 
inated. Arterial thrombosis is due in a large number of cases to 
simple stagnation of blood. Thus the arteries leading to a district, 
in which (owing to morbid processes going on in it) the blood has 
ceased to circulate, get filled secondarily with coagulum. And in 
precisely the same way, if an artery be ligatured, or obliterated at any 
point by the pressure of a tumor or tourniquet, the proximal portions 
of the vessel up to the nearest branch becomes the seat of throm- 
bosis. Not unfrequently also, when the circulation is simply feeble, 
obliteration of an artery by coagulation of its contents takes place. 
This occurrence in the smaller branches of the pulmonary artery is 
a common cause of pulmonary apoplexy. It is occasionally also 
observed in the arteries of the extremities and even in the aorta 
itself. Diseases of the inner coat of arteries (atheroma, calcification, 
arteritis, and syphilis), are all of them liable to induce thrombosis and 
consequent obliteration. Among arteries especially liable to suffer 
thus are those of the base of the brain and of the extremities. The 
varieties of the arterial clots and the changes which take place in 
them are identical with those already described in connection with 
veins." (Bristowe.) 

Treatment. — (See remarks upon Embolism and phlegmasia alba 
dolens.) 



ARTERIO-SCLEROSIS. 

(Arterio-capillary Fibrosis.) 

"Definition. — A condition of thickening, diffuse or circumscribed, 
of the intima, consequent upon primary changes in the media and 
adventitia. The process leads, in the larger arteries, to what is 
known as atheroma or endarteritis deformans. 

" Etiology .—As an involution process arterio-sclerosis is an ac- 
companiment of old age, and is the expression of the natural wear 
and tear to which the tubes are subjected. Longevity is a vascular 
question, and has been well expressed in the axiom that ' a man is 
only as old as his arteries.' To a majority of men death comes 



DISEASES OF THE HEART, 815 

primarily or secondarily through this portal. The onset of what 
may be called physiological arterio-sclerosis depends, in the first 
place, upon the quality of arterial tissue (vital rubber) which the 
individual has inherited, and secondly, upon the amount of wear and 
tear to which he has subjected it. That the former plays the most 
important role is shown in the cases in which arterio-sclerosis sets in 
early in life in individuals in whom none of the recognized etiologi- 
cal factors can be found. Thus, for instance, a man of twenty-eight 
or twenty-nine may have arteries of sixty, and a man of forty may 
present vessels as much degenerated as they should be at eighty. 
Entire families sometimes show this tendency to early arterio-sclero- 
sis, a tendency which cannot be explained in any other way than 
that in the make-up of the machine bad material was used for the 
tubing." (Osier " Practice of Medicine.") 

The chief causes of arterio-sclerosis are alcohol, gout, and syphi- 
lis. It is supposed that plumbum and barium can cause it. Over- 
eating may cause it by overfilling the blood-vessels, particularly in 
sedentary persons who take but little exercise. Overwork, which 
taxes the muscular strength, may cause it, by raising the blood-pres- 
sure in the arteries. Renal diseases, especially Bright's disease, 
may cause sclerosis, but it has not been proved whether the sclerosis 
is a primary or secondary affection. It is a fact, however, that the 
two diseases are generally found in the same persons. The main 
subjective symptoms of arterio-sclerosis are, (1) Increased tension 
in the vessels. (2) Hypertrophy of the heart due to this tension. 
(3) When the coronary arteries are involved there occurs throm- 
bosis of the heart with sudden death, aneurism, rupture, and, most 
common of all, angina pectoris (although angina may occur when 
the coronary arteries are healthy). (4) The patient may suffer 
from all the symptoms of cardiac weakness, dyspnoea, scanty urine, 
and dropsy. The cerebral symptoms of arterio-sclerosis are cere- 
bral hemorrhages, miliary aneurism resulting in apoplexy, hemiple- 
gia, monoplegia, or aphasia. From these attacks partial or complete 
recovery may follow. The vertigo of arterio-sclerosis is often laid 
to other causes, as Manniere's disease, indigestion or billiousness. 
This vertigo has been well described by Prof. Archibald Church, of 
Chicago. He says: 

" When a man past the prime of life, without any previous seri- 



816 THE PRACTICE OF MEDICINE. 

ous illness, becomes suddenly faint, has a swimming in the head, a 
feeling of giddiness of distinct gyration, of darkness, and impending 
death, or several of these sensations, he usually at once seeks advice 
in grave apprehension (sometimes well founded) of approaching 
cerebral hemorrhage, and usually gets a cholagogue cathartic, or is 
told that his stomach is wrong, and sometimes is told rightly. But 
cases are constantly presenting themselves in which such vertiginous 
attacks are happening at shortening intervals ; the patient gives up 
his tobacco, his spirits (if he is a drinker), cuts down his meat, 
takes to some of the many waters recommended, has Turkish baths, 
and gains only moderate relief or none at all. If he is carefully ex- 
amined he will probably present a well-defined tortuous frontal ar- 
tery, a distinct arcus senilis, a strong, even a clanging, second sound 
of the heart, sometimes reduplicated, and yield a sphygmogram in- 
dicative of increased arterial tension. The pulse may be abnormally 
slow or arhythmic, the urine scant, and a trace of albumin is not 
rare. He finds that exertion of a moderate degree precipitates the 
attack, that he cannot endure a temperature at all above the usual, 
and often a change of position from recumbency to the upright is 
the occasion of a " blur " or of giddiness. 

The attack itself is, as already indicated, widely variable in differ- 
ent patients. A fulness and throbbing in the head, a feeling of heat 
in the scalp, and a blur before the eyes are usually mentioned, and at 
such times marked paleness is noticed, followed, as a rule, by con- 
siderable redness of the face. There is a desire to get in the open 
air, and badly-ventilated or close apartments are unendurable. An 
habitual smoker will sometimes find tobacco smoke repugnant. In 
more severe forms, the patient may stagger, fall, or gradually sink 
to the ground ; he cannot speak for a few seconds, though conscious- 
ness is rarely completely lost. The recumbent position is usually 
sought, or the patient clings to some object, and after a period of 
from five to twenty minutes the feeling passes away, leaving him 
rather languid, with an inclination to sleep, and usually mentally 
depressed and apprehensive. At first, he attributes the attack to 
anything and everything that in his estimation can cause a depart- 
ure from health, and usually establishes a close watch upon his diet, 
habits, and mode of life ; is inclined to avoid exercise or exertion of 
any sort, fearing to precipitate an attack, or to go by himself on the 



DISEASES OF THE HEART. 817 

streets — in short, becomes an invalid with hypochondriacal tenden- 
cies." 

In a remarkable monograph on this subject, Professor J. Grasset, 
of Montpellier, divides the vertigo of arterio-sclerosis into three forms : 
(1) simple vertigo ; (2) vertigo with epileptiform crises ; (3) vertigo 
with slow pulse and syncopal or epileptiform attacks. 

Osier says there are three forms of this disease, namely : 

(a) " Nodular form," of which he says, " the affection is really 
a mesarteritis and a periarteritis, and which may lead to rapid dila- 
tation or to production of an aneurism, particularly in the early stage. 
(For a complete description of the degenerative changes refer to 
Osier's " Practice.") 

(b) " Senile Arterio-sclerosis. — The larger arteries are dilated 
and tortuous, the walls thin but stiff, and often converted into rigid 
tubes. The subendothelial tissue undergoes degeneration and in 
spots breaks down, forming the so-called atheromatous abscesses, the 
contents of which consists of a molecular debris. They may open 
into the lumen, when they are known as atheromatous ulcers. The 
greater portions of the intima may be occupied by rough calcareous 
plates, with here and there fissures and loss of substance, upon which 
not infrequently white thrombi are deposited. Microscopically there 
is extreme degeneration of the coats, particularly of the media. 
Senile atrophy of the liver and kidneys usually accompanies these 
changes. Senile changes are common in other organs. The heart 
may be small and is not necessarily hypertrophied. In seven of four- 
teen cases of Councilman's series there was no enlargement. Brown 
atrophy is common. (Osier.) 

(c) " Diffuse Arterio-sclerosis. — The process is widespread 
throughout the aorta and its branches, in the former usually, but not 
necessarily, associated with the nodular form. The subjects of this 
variety are usually middle-aged men, but it may occur early." (lb.) 

Treatment. — In the early stages of sclerosis before any local 
symptoms are manifested, the patient should be frankly informed of 
his condition and the nature of the disease. He should be advised 
to abstain from the habitual use of alcohol, from large eating, espe- 
cially of animal food, from drinking calcareous or iron waters, from 
extreme physical exertion, and if the patient is over forty from vio- 
lent athletics of all kind. The urine should be kept free and abund- 

52 



818 THE PRACTICE OF MEDICINE. 

ant by the use of pure or sodic waters and the bowels kept open by 
laxative food or laxative waters. I have already treated of the high 
tension pulse not due to sclerosis. This condition should not be con- 
founded with the former. The remedies for sclerosis are mainly 
physiological, i. e., those drugs which taken into the circulation act 
upon the coats of the arteries in such a manner as to prevent the 
hardening and degenerative process. 

The principal remedies are the iodides of potassium, sodium, 
lithium, aurum, barium, and argentum. The old school all over the 
world seem to prefer the iodide of potassium, and their reported 
experience is on the whole very favorable. If the patient is strong 
and muscular the potassium salt is well borne, and capable of arrest- 
ing and holding the disease in check. If the muscles of the patient, 
particularly of his heart shows any weakness the sodium salt is to be 
preferred. Potassium sometimes increases arterial tension, while 
sodium does not. The dose in general use is five to fifteen grains 
daily : patients require varying doses ; I have found the dose most 
useful is from two to five grains three times a day. Under its use 
the tension, vertigo, dyspnoea, cardiac disturbances, etc., will soon 
show improvement in severity. It should be continued until the 
pulse is soft, even if it requires months. The other iodides can be 
chosen from the symptoms of the drug which is combined with 
iodine, as the iodide of gold for the senile melancholia, which is often 
a prominent symptom. Other medicines are phytolacca, veratrum 
viride, phosphorus, mercurius plumbum, (which is closely homeo- 
pathic), aurum mur. et sodii, and ergot (in case of gangrene). 

The palliatives are (as in vaso-motor arterio tension, which some- 
times complicates sclerosis) amyl, glonoine, nitrite of sodium, cobalto- 
nitrite of potassium, gelsemium, and in rare cases aconite and pis- 
cidia. (This last drug in twenty to fifty drops has been found use- 
ful in angina pectoris.) Daily warm (not hot) baths by sponging, 
the rain-bath, or whole bath, are useful, for they relax the arterial 
coats. 

The vertigo of arterio-sclerosis cannot be treated entirely symp- 
tomatically. Unless a medicine has a physiological or homeopathic 
relationship to the pathological condition it will not even palliate. 
The remedy which has given me the best results is zincum-phosphide 
in the 3x trituration. Both phosphorus and zinc are strictly homeo- 



DISEASES OF THE HEART. 819 

pathic to sclerosis of the arteries. The phosphide of lead should be 
equally efficacious, but I have never used it. Dr. Church recom- 
mends iodide of potassium. In some cases silica, calcarea, salicylate 
of soda, nickel, picric acid, and picrate of zinc are indicated. 

There is a pulse just the opposite to that in arterio-sclerosis. Dr. 
C. L. Dana describes it as follows in a paper entitled " The Apo- 
plectic Pulse and its Treatment." " There are many conditions of 
the heart, blood-vessels, and blood, underlying attacks of cerebral 
hemorrhage. I refer to a class of cases in which the blood-vessels 
become gradually dilated and tortuous. The pulse at the wrist is 
very full and not very hard ; the temporal arteries are very promi- 
nent. The patients do not usually have much kidney or heart disease, 
though the latter organ is a little dilated. Between the ages of forty- 
five and sixty-five, i. e., at the apoplectic period of life, these patients 
without warning, and usually while feeling physically, particularly 
well, have a more or less severe attack of hemiplegia. After the 
hemiplegia they suffer a long time, not so much from the paralysis 
which may be slight, as from mental and cerebral disturbances ; 
they are greatly depressed and sleep badly, have vertigo, confusion 
of thought, cannot read or work, feel very weak, and are very ner- 
vous and emotional. They seem to be quite wrecked physically and 
mentally, and this is all out of proportion often to their paralysis or 
the brain lesion. This varies much in intensity in different indi- 
viduals. They gradually improve under proper conditions ; but may 
have another attack one to five years later. 

A study of the pulse in these cases shows quite a different state 
of affairs from that formed in ordinary apoplectics. It is of ex- 
tremely great amplitude ; the pre-dicrotic notch is very deep and 
close to the percussion wave. The dicrotic notch is very deep and 
the dicrotic wave is short, so that the lever may fall to the respira- 
tory line and make a horizontal line before it starts up on the next 
beat. The total area of the wave is small. All this means that 
these patients have had, for many years, an extreme peripheral re- 
sistance in the small arteries and capillaries. The heart pounds for 
years against the resistance, dilates the arteries, and becomes itself 
hypertrophied. The blood, driven with a quick stroke through the 
enlarged vessels, causes finally a rupture. The shock, or some other 
cause, then leads to a weakening of the heart. We have, as a result, a 



820 THE PRACTICE OF MEDICINE. 

sphygmograph showing a weak heart, large arteries imperfectly 
filled, a pulse that has relatively a low tension, and an abnormal 
peripheral resistance still present. This condition calls for a differ- 
ent treatment from that in apoplexy, where the arteries are greatly 
thickened, rigid, and the tension continues high. In the cases to 
which I call your attention nitro-glycerin, and arterial relaxers gen- 
erally, do no good, except for a short time. They simply make the 
walls more flabby, but do not cause the vessels to be more filled. 
Strophanthus, and in some cases digitalis, however, strengthen the 
heart, tighten the vessels, and fill them better. But the essential 
thing still remains. These patients have all along had too great a 
peripheral resistance, which, as Broadbent shows, lies mainly in the 
capillaries. This is due to impoverished conditions of the blood or 
to diathetic irritations such as rheumatism, gout or lithaemia, or to 
other conditions causing atrophic kidneys. The physician, therefore, 
must, above all, attend to these points, and pay relatively little at- 
tention to the heart and arteries. I find that these patients improve 
most rapidly under the use of tincture of iron and salicylate of soda. 
These remedies, with spartiene, strophanthus, or digitalis, given oc- 
casionally are of enormous service, producing their effects at times 
almost magically. It is important to place these patients also on a 
diet of vegetables, fruit, a little meat and a moderate amount of milk. 
I believe that by watching the pulse and the urine, and by occasion- 
ally examining the blood of persons who have had one attack of hem- 
orrhage, we can keep them from having a second seizure, at least 
until many years have passed. This it has always seemed to me is 
the true aim of the therapeutics of cerebral apoplexy. I call atten- 
tion to this particular condition because I believe the treatment in- 
dicated is different from that in other types in which iodides, glonoine, 
mercury, and other drugs may be much more specifically indicated. 
I believe that it is always accompanied by cerebral hemorrhage, 
never by thrombosis. Cerebral hemorrhage, however, may and often 
does occur in persons who have rigid and atheromatous arteries 
which are not dilated. On the other hand, many persons with very 
dilated arteries do not have hemorrhage, though they are liable to it. 
The pulse is essentially one of hemorrhage, and its presence may 
forewarn, and may help in diagnosis and treatment. The serious 
and important feature in these pulse curves is the depth of the predi- 



DISEASES OF THE HEART. 821 

erotic notch. This, with the vertical line of ascent, shows a much 
dilated artery whose walls have lost resistance. The deep dicrotic 
notch indicates a weak heart and imperfectly filled arteries. While 
this condition is one free from risk of hemorrhage, it indicates a 
badly nourished brain, and the patients with it complain much of 
insomnia, vertigo, mental confusion, and depression." 

RESUME. 

(1) There is a class of cases in which the arteries are extremely 
dilated and their walls thin and soft, giving a characteristic sphygmo- 
gram showing so-called virtual tension. 

(2) Persons with this pulse, if they have apoplexy, have hemor- 
rhage, not thrombosis. 

(3) The treatment is different from that indicated for persons 
who have rigid arteries and actual high tension. 

(4) The treatment is essentially directed to strengthening the 
vascular system and lessening peripheral resistance as specifically 
indicated above. 

(5) Careful watching of these cases enables one to protect them 
against other attacks." 

The medicines homeopathic to the above condition are secale, 
hydrastis, ustilago, millefoil, trillium, zinc phosphide, and ferrum 
phosphate. They are most appropriate in the third attenuation. 
As for physiological remedies I should prefer coronilla or convalla- 
ria to digitalis. Salicylate of soda should not be given in larger 
doses than one or three grains lx or crude every four or six hours. 



THE GEOGRAPHY OF HEAET DISEASE. 

After considerable investigation of this subject I have arrived at 
the conclusion that any attempt to define the geographical limits of 
all heart diseases is almost an impossibility . Idiopathic inflamma- 
tory cardiac diseases are very rare, and when they do occur may 
arise in any climate and in any country. Inflammatory diseases of 
the heart are generally secondary, or are caused by some constitu- 
tional disease. Therefore, we are obliged to ascertain the geograph- 
ical limits of those diseases which cause them. This we can do with 



822 THE PRACTICE OF MEDICINE. 

considerable accuracy. The constitutional diseases which are most 
likely to cause cardiac disorders are : (1) Rheumatism, and (2) 
Bright's disease, to which may be added as occasional causes, la 
grippe, scarlet fever, and diabetes. 

In comparing the mortality statistics of rheumatism, Bright's 
disease, and diabetes, I find that the same climatic influences induce 
them all. The statistics collected by Dr. C. W. Purdy are very 
instructive. He found that Bright's disease was most common in 
the following states — I give them here with the ratio of deaths from 
Bright's disease per 1000 deaths from all other causes. 

California 7-02 

Michigan 5-06 

Minnesota 3-86 

Ohio 6 00 

Pennsylvania 7 ■ 68 

Wisconsin 4-99 

Illinois 4-73 

West Virginia 4-46 

It will be observed that all these states lie north of " Mason and 
Dixon line." It is in these states that statistics show that rheuma- 
tism and Bright's disease is most prevalent. 

The climatic condition of these states consist of coldness and 
dampness mainly, and often of high altitude. We will now glance 
at those states where Bright's disease is less frequent. 



New Jersey 28-55 

New York 20-13 

Connecticut 14-48 

Massachusetts 13-00 

New Hampshire 12-70 

Maryland 11-52 

Vermont 10-33 

Maine 9 34 



Arkansas, percentage to 1000 . . 1-95 

Georgia 1-67 

Indiana 3 *46 

Iowa 3-45 

Kansas 2 • 50 

Kentucky 3-28 

Mississippi 2 • 60 



Missouri 2-89 

Nebraska 1-68 

North Carolina 1 -85 

South Carolina 2-47 

Tennessee 1*11 

Texas 2 14 

Virginia 2-95 



Florida is not given, but I believe from my observations and inter- 
views with physicians of that state that the percentage is less even 
than in Georgia and other Gulf states. You will observe the con- 
trast between West Virginia, which is mountainous, very damp and 
cold, and East Virginia, which is warmer, lower, and less humid. 
The percentage in the former is double that in the latter. The sta- 
tistics of rheumatism conform with that of Bright's disease in the 
Southern states ; as in West Virginia, with its coldness, moisture, 
and high altitude, there rheumatism is more prevalent. 

The following grouping was suggested by Mr. Gannet, the geog- 



DISEASES OF THE HEART. 



823 



rapher of the census. It gives clearly the regional geography of 
Bright's disease. 

"DEATHS FROM BRIGHT'S DISEASE IN EACH 1,000 DEATHS IN 

THE UNITED STATES FOR 1880. 

In Grand Groups, Showing Climatic Features and Population. 



Region. 



Ratio to 

1,000. 



Mean 
Temper- 
ature. F. 



Mean 
Rainfall 
in Inches. 



Elevation in 
Feet. 



1. North Atlantic Coast region 

2. Middle Atlantic Coast region. . . . 

3. South Atlantic Coast region 

4. Gulf Coast region 

5. Northeastern hills and plateaus. . 

6. Central Appalachian region 

7. Northern lake region 

8. The interior plateau region 

9. The Ohio River belt 

10. Southern Central Appalachian re- 

gion... 

11. Southern interior plateau 

12. South Mississippi River belt 

13. North Mississippi River belt 

14. Southwest central region 

15. Central region (plains, etc.) 

16. Prairie region 

17. The Missouri River belt 

18. The Northwestern region 

19. Pacific Coast region 

20. Region of Western plains 

21. The Cordilleran region 



17-38 
19-73 
2-59 
9.41 
11-20 
8-23 
717 
8-32 
5-83 

2-63 
2-99 
314 
3-73 



97 
70 
59 
80 
21 
72 
92 
04 



40-50° 

45-60 

60-65 

70-75 

35-45 

40-45 

45-50 

45-50 

45-55 

45-55 
67-70 
60-65 
40-50 
60-70 
50-60 
50-55 
40-55 
40-50 
45-65 
45-65 
50-60 



40-50 
45-55 
50-60 
55 
35-45 
35-40 
30-40 
40-45 
45-50 

45-50 
50-60 
50-55 
30-50 
35-50 
40-45 
25-40 
20-40 
30-40 
20-60 
10-20 
10-20 



100- 500 

Below 100 

Below 100 

Below 100 

500- 2,500 

Above 500 

200- 300 

100- 200 

300- 1,000 



1,000- 
Below 

100- 
Above 

100- 

500- 
About 

500- 
Above 

100- 
1,500- 
4,000- 



2,000 

1,000 

300 

500 

500 

1,500 

1,000 

1,000 

1,000 

2,000 

5,000 

10,000 



Turning to the statistics of diabetes (glycosuria), we find that it 
agrees very nearly with that of Bright's disease. 

The states where it is most prevalent are : 

Indiana 2 • 72 

Iowa 2-42 



Vermont (percentage to 1000) . 6-36 

Maine 4-41 

Connecticut 3*37 

Ohio. 3-23 

New York 2-20 

Illinois 2-11 



Michigan 2-68 

Wisconsin 2-81 

Massachusetts 1-96 

California 1-99 



The states in which the disease is least prevalent are Alabama, 
Arkansas, Georgia, Kansas, Kentucky, Louisiana, Maryland, Minne- 
sota, Mississippi, Missouri, Nebraska, New Jersey, North and South 
Carolina, Pennsylvania, Texas, and Virginia. In these states the 
death rate ranges from about .60 in Alabama, Arkansas, Minnesota, 
and Tennessee, to an average of 1.50 in the other states. 



824 THE PRACTICE OF MEDICINE. 

The regional geography of Bright's disease and rheumatism is 
very similar to that of diabetes. In other words, the mortality 
increases as we go from the Gulf and Southern Atlantic states to the 
Northern and Middle states, the region of the North Atlantic Coast, 
the shores of the Great Lakes, and the North Pacific states. 

Different parts of each state are not equally causative of rheu- 
matism or Bright's disease. I call your attention to the difference 
between Virginia and West Virginia. The same difference is prob- 
ably found in those states which are partly flat and partly moun- 
tainous. In the regions of highest altitudes heart diseases will be 
more frequent than on lower ground, especially in the Southern 
states. Even in the Northern states, I think, the same difference 
will obtain. There may be some exceptions to this rule, as when 
the high lands are dry, as in the mountains of North Carolina, 
Georgia, New Mexico, and Arizona. 

The geography of functional diseases of the heart, whether arising 
from some irritation or lesion of the cardiac nerve-centres in the 
brain and spinal cord, in the nerves of the heart itself, or reflexes 
from irritation of other and remote organs, cannot be given with 
much accuracy. I can only suggest that all functional affection, 
local or reflex, to which the heart is subject, are more common in 
large towns and cities than in the country and rural villages. This 
is due to the excitement and competition in all kinds of business, 
and the rush and worry of the intense social life ; to which may be 
added the prevalence of dyspepsia, hepatic disorders, and affections 
of the female reproductive organs. I believe it can be substantiated 
that these functional disorders are more common in Northern than 
in Southern cities ; and oftener found in the cities of high altitudes 
than in those on the plains. 

In my studies of English and Continental authors, I find that 
the cold, humid and high altitudes in those countries are considered 
to be the chief habitat of inflammatory diseases of the heart. I 
cannot find any definite information as to the localities where func- 
tional disorders most prevail, but I see no reason why the chief 
cities of England and the north of Europe should not be as much a 
source of these disorders as in the United States. As for the 
geography of heart disease in Asia, Africa, Australia, and South 
America, no statistics are obtainable by me, but I believe the same 



DISEASES OF THE HEART. 825 

laws prevail in those countries as in North America. In a paper 
of this scope, I am not supposed to give any practical deductions 
which would apply to the treatment of cardiac disorders. Nor is it 
really necessary, for the inference is plain ; that as an aid to treat- 
ment, the sufferer from cardiac diseases should seek those regions 
and climates in which Bright's disease and rheumatism are least 
prevalent. 

A review of these investigations substantiates the following con- 
clusions : 

(1) That the chief features of climate in the United States 
which most strongly tend to increase the death rate from inflamma- 
tory, acute and chronic, heart-disease, are cold, moisture, and change- 
ability of temperature. 

(2) That the elements of climate which tend in the greatest 
degree to decrease the death rate from such diseases are warmth, 
dryness, and equability. 

(3) That cold most markedly increases the mortality from heart- 
disease when associated with moisture, a comparatively low temper- 
ature being well borne if the atmosphere is a dry one. 

(A) That a comparatively high degree of humidity of the atmos- 
phere does not markedly increase the mortality from heart disease if 
accompanied by warmth and equability. 

(5) That the most unfavorable residence localities for patients 
afflicted with heart disease in the United States are comprised within 
the Atlantic Coast region and Northeastern hills, which include the 
states of New Jersey, New York, Connecticut, Massachusetts, New 
Hampshire, and Vermont ; also those regions of high altitude which 
comprise the states of Colorado, California, and Oregon. 

(6) That the most favorable residence localities are chiefly within 
the Southern interior, and especially include the states of Tennessee, 
Georgia, North Carolina, Arkansas, Texas, Florida, Arizona, and 
New Mexico. 

(7) Finally, a practical lesson may be learned from these inves- 
tigations as follows : That, since climate so decidedly influences the 
mortality from heart disease, those who are afflicted with the disease 
or possess strong hereditary or other tendencies thereto should wear 
such garments as most directly tend to neutralize the evil influences 
of climate over the disease — viz., those combining the minimum 



826 THE PRACTICE OF MEDICINE. 

power of radiation of body heat with the highest hygroscopic prop- 
erties ; and since wool possesses these qualities to a degree unap- 
proached by any other textile, all-wool garments should be worn next 
the skin throughout the year. 

Another deduction relating to functional disorders of the heart 
may be stated as follows : In view of the fact that these disorders 
are more frequent in large towns and cities, especially in high alti- 
tudes and latitudes, it behooves physicians to order such patients 
whose disorders are not relieved by medicine or hygiene, to remove 
to the country or small villages in those regions which possess a 
warm equitable climate, in warm valleys and plains of low altitude. 
As for those diseases which are universal, namely : la grippe, scarlet 
fever, typhoid fever, and certain specific maladies, they have no 
geography. We can only say that they are more prevalent in large 
cities along lines of travel. 

In this we may also include cases of heart-strain from undue 
exertion : the abuse of alcohol, and the excessive use of coffee, tea, 
and such drugs as quinine and the so-called antipyretics. 



NON-MEDICINAL METHODS OF TREATING DISEASES 
OF THE HEART. 

There have been several such methods practiced from time to time. 
Some of them have been tested and found inadequate — too much was 
claimed for them by their enthusiastic originators. One of the 
earliest methods was that of hydropathy, introduced and practiced by 
Priessnitz. While this method was sometimes successful in the 
hands of its founder and his followers, its failures were many, and 
the treatment often disastrous. But Priessnitz's early methods have 
been greatly improved upon. The latest and best application of 
hydrotherapy as practiced by Dr. Simon Baruch, of New York, if 
properly carried out, has been attended with very gratifying results. 
The milk-cure, so-called, has been quite successful in some desperate 
cases as illustrated by the following case narrated in the " St. Peter- 
burg Med. Wohn.," No. 32. He refers to the " Carell Milk Cure 
Method." Dr. Koppel, the reporter, states it was a case of dilatation 
of the heart, which he treated first with the milk-cure and then with 



DISEASES OF THE HEART. 827 

digitalis. The patient was a man, twenty-nine years of age, whose 
father had died at fifty of heart disease, and who had a brother also 
with that disease. He had passed through both scarlet and typhoid 
fever as a child, but does not appear to have any heart trouble until 
much later. During a couple of years he noticed that his pulse was 
very frequent. He smoked a great deal and drank deeply ; according 
to his own account, he had, however, for a year reduced his potations, 
only taking two bottles of beer and a half-bottle of Madeira daily. 
The first sign of his trouble appeared in the summer of 1890, when, 
on the occasion of a fire at his store, he fell fainting, after running 
a short distance. He soon regained consciousness, and noted no 
change in his health. In the winter he suffered severely from influ : 
enza, only recovering very slowly, and in the spring following he 
gradually lost strength. About a week after his marriage, which 
occurred in July, 1891, he was seized with weakness at a company, 
and was taken home in a carriage. Difficulty in breathing and faint- 
ness occurred often, with swelling of the feet. 

When he came under Dr. Koppel's care, he showed a massive 
bony structure with a moderate amount of fat ; his face and upper 
extremities were somewhat turgid and slightly cyanotic ; the lower 
extremities were cedematous, thorax normally formed. The lungs 
showed vesicular breathing in front ; behind, especially in the lower 
portions, moist rales ; slight bodily exertion caused increased dysp- 
noea. He had a hard, frequent cough. The impulse of the heart's 
apex was neither visible nor perceptible to the touch, while there 
was a diffuse palpable arching forward of the region of the heart ; 
epigastric pulsation plain. Diagnosis was : Dilatation of the heart, 
probably caused by a fatty degeneration of the heart-muscle as a 
result of alcoholism. The milk-cure was used during ten days with 
general improvement. The milk-cure is in a measure a hunger cure ; 
but, as Hirschfeldt has noted, such a scant diet can be easily endured 
for a couple of weeks. It does not strengthen the heart-muscle, but 
aids it by lessening the demand upon it, so that they are not too great 
for a comparatively weak heart." 

The digitalis given after the milk-cure was abandoned produced a 
temporary strengthening of the heart's activity. Carell gives twenty 
to twenty-six ounces of milk daily to begin on, increasing it to seventy- 
five ounces very soon ; after this the deficient nourishment may be 



828 THE PRACTICE OF MEDICINE. 

made up by three ounces of zwieback. Koppel gives a carefully pre- 
pared table, showing the results obtained during the milk-cure." 

The " grape-cure " is credited with many successes. It consists, 
as nearly as I can ascertain, in confining the patient to a diet of 
grapes ahnost entirely, to which is sometimes added a small quantity 
of bread or zwieback. Somewhat similar is the " whey-cure," prac- 
ticed in some parts of Germany and Switzerland. 

Oertel's system, which consisted of gymnastic exercises — princi- 
pally mountain and hill climbing — was fully described in my " Lec- 
tures on Diseases of the Heart," third edition. The chief aim of 
this method is to develop the muscular tissue of the heart by such 
exercises as tend to increase its action in a methodical manner. Dr. 
William A. Hammond advises systematic stair-climbing as equally 
beneficial. But this method can only be useful in dilatation, and in 
certain nervous and degenerative diseases. It can by no possibility 
be useful in arterio-sclerosis, angina pectoris, or hypertrophy. 

Massage of the heart has been advocated and practiced, but I 
cannot conceive how it can be used except in a very few cases. The 
manipulations, as advised, consist in pressure made in various direc- 
tions upon the walls of the thorax in such a way as to affect the heariv 



SCHOTT'S METHOD OF TREATMENT OF CHRONIC 
DISEASES OF THE HEART. 

A novel method of treating diseases of the heart, and one that is 
yearly growing in favor with the medical profession of Europe, is 
the balneological gymnastic method of Schott. This treatment was 
originated and developed at Bad-Nauheim, Germany, not far from 
Frankfurt-on-the-Main, and has been employed by the physicians of 
the place for the past ten years or so. Dr. Beneke was the first to 
announce the beneficial effects of balneological treatment in cases of 
heart disease due to recent endocarditis resulting from articular 
rheumatism. But two brothers, Dr. August Schott, deceased, and 
Dr. Theodore Schott, are entitled to the credit of having applied 
it to chronic diseases of the heart, organic and functional, and of 
having brought it to its present perfection. And to them alone 
belongs the merit of having devised the system of light gymnastics, 
which forms an important feature of this Schott method. 



DISEASES OF THE HEART. 829 

The waters of Bad-Nauheim are not only rich in chloride salts, 
mainly chlorides of sodium and calcium, but are highly charged with 
carbonic acid. At first patients are given baths that are simply 
saline devoid of gas, and later on, as their condition permits, effer- 
vescing baths. The temperature of the baths varies from about 
32.6° C. At first to 30.5° C. or even lower in exceptional cases. 
Gradually as the patients learn to bear the lower degrees of tempera- 
ture, the proportion of salts is increased and the duration of the 
baths is lengthened to eighteen or twenty minutes. But one bath is 
taken daily and as a rule it is omitted every fourth day, the frequency 
of this omission being determined by the condition of the patient. 
Bathers are instructed to remain motionless during the bath, and 
afterward to lie down warmly covered and rest for at least an hour. 

The salts and carbonic acid stimulate the heart reflexly through 
the impression made upon the sensory nerves of the skin, the stimulus 
thus produced being conveyed to the nerve-centres and through them 
to the heart. Cardiac energy is increased and the rate of cardiac 
contractions is diminished. This is shown by the pulse, which becomes 
slow, full, strong, and regular ; indeed, the quality of the pulse is so 
greatly improved that a pulse weak before the bath becomes almost 
incompressible toward the end of the bath. Still more striking 
evidence of the effect on the heart is obtained by percussion of the 
organ. If the area of deep-seated cardiac dulness be carefully out- 
lined just prior to a bath, and this procedure repeated immediately 
thereafter, the field of dulness will be found to have diminished in 
all directions, thus showing actual lessening in the size of the organ. 

Subjectively patients experience but slight discomforts. The ini- 
tial sense of chillness is quickly succeeded by agreeable warmth ; if 
some oppression of the chest or epigastrium be experienced at first, 
it will be found to lessen with each succeeding bath ; dispcena is not 
occasioned, but on the contrary the respirations are rendered deeper 
and less rapid. Increased flow of urine after the bath betokens the 
diminished passive hyperaemia and improved arterial circulation. 

A course of such balneological treatment averages about seven 
weeks, after which a month of rest is advised, followed then by a 
second shorter term of baths. 

The second and highly important feature of this method consists 
of light exercises. These "gymnastics" are made up of movements 



830 THE PRACTICE OF MEDICINE. 

of extension, flexion, and rotation of the extremities and trunk. They 
are made slowly and steadily with a brief pause for rest after each 
movement, and carefully apportioned resistance is applied by a trained 
attendant. It should also be the duty of the attendant to watch the 
pulse and respiration, and insist on rest so soon as circulatory or res- 
piratory embarrassment is detected. 

Carried out in this manner the gymnastics exert the same favor- 
able effect on the heart as do the baths. It is, however, not quite 
so pronounced or enduring, and of course is brought about through 
the motor nerves. These exercises are also given once a day. 

According to Dr. Schott this treatment is suitable to all forms of 
chronic heart diseases excepting pronounced general arterial scler- 
osis and aneurisms of the heart or great blood-vessels, or, in other 
words, conditions in which heightened intra-vascular and intracar- 
diac blood-pressure Would be dangerous. Valvular lesions and dila- 
tation of the heart from over-strain form official indications for this 
method. 

Fatty degeneration and chronic myocarditis, provided the heart- 
muscles be not damaged beyond all possibility of repair, are also 
favorably influenced. Inorganic diseases, such as the so-called " cur- 
able mitral regurgitation," are cured and more speedily than any 
other mode of management. Neurotic hearts and the functional dis- 
turbance of Graves's disease are likewise remarkably affected for 
the better. Moreover, a special recommendation of this method con- 
sists in the fact that loss of compensation does not contraindicate its 
employment, as is the case with Oertel's system of mountain climb- 
ing. To be sure, the Schott method will not cure or even permanently 
benefit all cases of heart disease in which the organ is damaged beyond 
the possibility of repair, but the results already obtained seek to 
prove it to be more efficacious in this class of cases than any other 
known mode of management. Its chief drawback lies in the fact 
that the paraphernalia requisite for its employment, including a corps 
of trained attendants, and the possibility of harm being done by 
ignorant or unskillful practitioners, renders its employment by the 
general physician impracticable, and that therefore it must be left 
to specialists in the treatment of cardiac diseases. 

Finally, although natural waters are employed at Bad Nauheim, 
Dr. Schott advised its use by means of artificial waters, which if 



DISEASES OF THE HEART. 831 

properly prepared are capable of producing the same favorable 
results. 

Accordingly there are two establishments in which the method is 
now carried out in this way. One is in Copenhagen, Denmark, 
under the charge of Dr. Israel, and the other is in Chicago. 

Dr. Robert H. Babcock, who has supplied the author with this 
description of the Schott method, derived his information from a 
personal investigation of the treatment at Bad-Nauheim, whither he 
went for the double purpose of treatment and acquiring practical 
familiarity with the details of the method. He had suffered for ten 
years with heart disease. His trouble dated from severe and repeated 
over-strain, but owing to a mitral murmur had been considered a 
chronic endocarditis induced by the too great and repeated physical 
effort acting on valves already somewhat damaged by an attack of 
scarlatina in childhood. Upon arriving in Bad-Nauheim he pre- 
sented all the signs and many of the symptoms of dilatation of both 
ventricles. A mitral murmur was audible. At the end of five weeks, 
after he had taken but twenty-seven baths and the gymnastics for 
four weeks, his heart had returned to a normal size and the apex mur- 
mur had been converted into a prolongation of the first sound. His 
heart has remained normal since, although he has stopped gym- 
nastics and all other forms of treatment. The Doctor is so enthu- 
siastic over this treatment that he has established bathrooms and is 
now employing the treatment. 



CHAPTER IX. 
DISEASES OF THE NEEYOUS SYSTEM 



STRIDULOUS LARYNGISMUS. 

(False Croup, Spasmodic Croup, Laryngismus Stridulus.)) 

Definition. — A spasmodic irritability of the glottis. This is often 
mistaken for true or membraneous croup, but it is a distinct affection, 
and never runs into membraneous laryngitis. It is usually caused 
by a cold, which primarily attacks the larynx ; or a coryza which 
extends downward from the nose to the pharynx and larynx. It is 
rare under two years of age and over seven. The children are not 
sickly-looking, they are generally healthy and robust. The tendency 
seems to be hereditary, for it appears in families for several genera- 
tions, which is not the case in true croup. When death does occur, 
which is rarely, it is caused by a violent spasm of the glottis, for 
post-mortem examinations show no membrane, only an excess of 
mucus, and the glottis and vocal cords but little altered. 

The child affected with this disease may have a slight coryza dur- 
ing the day, or is put to bed well, when about midnight or in the 
early morning hours awakes with oppressed breathing, harsh croupy 
cough, and perhaps some huskiness of voice. The oppression and 
distress for a time seems very serious, but it passes off in an hour or 
two, when the child falls asleep and awakes the next morning feel- 
ing well. These attacks are repeated two or three nights in succes- 
sion, rarely longer. During the day the child may appear perfectly 
well, but in many instances is hoarse, has a brassy, barking cough, 
and a slight fever. These symptoms often alarm both parents and 
physician, who fear true croup. But true croup has a prodromic 
stage of several days, during which the child feels ill, is hoarse, and 
the croupy cough and stridulous breathing increases. 

Treatment. — In ordinary cases no treatment is really necessary. 



DISEASES OF THE NERVOUS SYSTEM. 833 

The symptoms spontaneously subside after the third night, leaving 
the child well, or with a slight catarrhal bronchial cough. In the 
early days of homeopathy, all croups were thought to be the same, 
and absurd claims were made for cures of croup, when no such claims 
were admissible. Benninghausen and others, and even some mem- 
bers of our school in this country to this day, assert that the three 
medicines, aconite, hepar sulphur, and spongia, are specific against 
dangerous croups. With a charlatinism which should be condemned 
they prescribed nine powders, three of each to be taken daily (each 
in the 30th); and this without regard to the dictum of Hahnemann, 
who declares that we must prescribe by the totality of the symptoms 
in every case. The fact is, that aconite is rarely called for. 

Gelsemium is generally indicated if there is slight fever during 
the day, aggravated at night, but often there is no fever day or 
night. 

Hepar sulphur is indicated in the majority of cases, and if given 
during the day, will usually modify, never altogether prevent, the 
attacks on the second or third night. 

Spongia may be useful, but only because it contains a trace of 
iodine and bromine, which are useful in both catarrhal and mem- 
braneous croup. 

Sanguinaria was considered a valuable remedy in all croupy 
coughs by the early botanic and eclectic physicians, and has sus- 
tained its reputation in our school. I doubt if it will cause mem- 
braneous laryngitis ; it does, however, cause a severe laryngitis, with- 
out the spasmodic element. The same may be said of hepar sulphur. 

Sanguinaria nitrate, however, is more poisonous, and may cause 
false membranes. 

When the physician is called at night, to see a child with spas- 
modic, croupy cough, he is expected to do something promptly. He 
generally, following the traditions of our school, gives hepar sulphur 
and spongia. These may modify the laringeal irritation, but not 
immediately. If continued through the day they are useful, but they 
do not help the spasm during the time they are given. The immediate 
remedies should be ipecac, belladonna, or gelsemium, as the symptoms 
demand. At the same time the throat should be swathed with warm 
water, after rubbing in vaseline, olive oil, or any oleaginous substance. 
During the day-time the child should be kept in the house if the 

53 



834 THE PRACTICE OF MEDICINE. 

weather is cool, and the room in which the patient stays should be at 
a temperature of 70° or 75° day and night, until the disease has sub- 
sided. 

On account ot the value of chloride of gold in spasm of the larynx 
(laryngismus stridulus), I have used in several cases iodide of gold 
for the spasmodic symptoms, when the child started up out of sleep, 
with a frightened expression and a crowing cough. It has acted 
favorably, and I recommend it in such cases in the 3x trituration. 
It should be kept in dark-glass bottles. 



PARALYSIS AGITANS (Shaking Palsy, Tremors). 

Definition. — A chronic affection of the nervous system, charac- 
terized by muscular weakness, tremors, and rigidity. 

Men are said to be more frequently affected than women. It 
rarely occurs under forty, but I know of two cases in women who 
were attacked at thirty without any assignable cause. It cannot be 
said to be hereditary, but its victims generally belong to neurotic 
families. Exciting causes are, exposure to cold and wet, business 
worries and anxieties, severe mental shock, and traumatism. I have 
seen it occur after cerebro-spinal and typhoid fevers. 

No constant lesions have been found, but there are certain fea- 
tures described by Parkinson which suggest that it may be caused by 
premature senility of certain regions of the brain. Certain portions 
of the brain may grow old before the others. Dubief says it is not 
a neurosis but a cerebro-spinal senility, differing from true senility 
only by its early onset and greater intensity. The disease begins 
gradually, unless due to a shock or injury. It may begin in one hand. 
It may be constant or intermittent. It may be associated with weak- 
ness and stiffness. It is aggravated after exertion, and is to a certain 
extent under the control of the will. It is readily diagnosed, and 
cannot be mistaken for chorea, except by the most superficial observer, 
but may be mistaken for insular sclerosis. Only the hands and feet 
may be affected ; the movements of the thumb and forefinger resemble 
the motions made in the act of rolling a pill. The ankle and wrist 
joints are weak. When the whole hand shakes it is not vertical but 
rotary. Any emotion exaggerates the movements. The attempt at 
a voluntary movement may check the tremor ; the patient may be 



DISEASES OF THE NERVOUS SYSTEM. 835 

able to thread a needle. One of the greatest surgeons of this country 
was able to perform the most delicate operations on the eye by an 
effort of the will, although before the moment of operation the shaking 
of his hands alarmed the spectators. The tremors, as a rule, cease 
during sleep, but not when the muscles are in repose when awake. 
The writing of the patient is tremulous and zig-zag. When the head 
is affected, the shaking may be vertical or rotary. Some authors 
deny that it affects the head, others (Bristowe) say the head is often 
affected. I am sure I have seen several cases of head tremors not 
due to sclerosis. 

There is always weakness and slowness of movement, but not 
complete loss of power. The rigidity of muscles of voluntary move- 
ment is marked. The attitude and gait are peculiar. The head is 
bent forward, the back is bowed, the arms held away from the body. 
The face is devoid of expression, and the lips move slowly. The 
voice is apt to be shrill and piping, and there is hesitancy in begin- 
ning a sentence, then the words are uttered rapidly, contrary to what 
occurs in insular sclerosis. In attempting to walk the steps are short 
and hurried. The patient appears to be running after his centre of 
gravity, but if he attempts to walk backward he falls over, after a 
few steps. 

Abnormal sensations of heat and cold are common. The mental 
conditions rarely show any change. Neurologists pronounce the dis- 
ease incurable, but advise arsenic, hyoscyamus and opium, as pallia- 
tives. Hydrochlorate of hyoscine will give more relief than any other 
medicine. Many cases have lately been reported which improved 
greatly under its use in doses of l-250th and l-100th of a grain, 
three times a day. Even these doses often aggravate some of the 
symptoms of the disease. In my cases I gave the 1-5 00 th of a grain 
with decided benefit, and without causing the slightest pathogenetic 
symptom. 

Dr. Samuel "Worcester (Arudt's i; System of Practice "), says : 
4i Plumbum and tarantula are the only two medicines from which I 
have seen good results."' He says the cases were not cured, only 
benefited. 

Dr. Goss Q' Practice of Medicine '') recommends rhus tox., stra- 
monium, and phosphoric acid, but I fail to find any cures made by 
them. 



836 THE PRACTICE OF MEDICINE. 

Khus may cure tremor of certain muscles and tendons when it 
has a rheumatic origin from exposure to cold and wet. 

Baryta muriatica should be tried. It is the great remedy for 
general or partial premature senility. It may be found curative in 
recent cases. 

Physostigma is recommended when no structural lesion exists, but 
it has been tested in European hospitals without good results. 

Sparteine sulphate has lately been used with good palliative 
effects for tremors due to various causes, and we may find in it a 
good palliative in paralysis agitans, and the tremors of tachycardia 
(exophthalmic goitre). Dr. Potts ("Therapeutic Gazette," June, 
1892) reports several cases of tremors of the hands which were 
greatly benefited by sparteine. One, a man of seventy-three who 
had fine tremors in both hands, no paralysis anywhere, knee-jerks 
decreased, arteries hard, marked venous congestion of the face, and 
loud systolic murmur at the aortic orifice. Sparteine was given to 
improve the condition of the heart, which it did, and the tremors 
almost ceased (an accidental discovery of its usefulness). Another 
case of violent tremors of both hands, with headache involving the 
entire head, had no heart disease but was easily excited or worried 
and had trembling of the tongue. He was greatly improved, but on 
taking arsenic and strychnine, the tremor returned ; and improved 
again under sparteine. It improved three cases of tremors in neu- 
rasthenics ; two old hemiplegics, one of locomotor ataxia, and one 
of meningitis following sunstroke, but did not benefit an old case of 
paralysis agitans. I think it would benefit morphine-eaters' tremors, 
and the tremors due to excessive use of tobacco and tea. The dose 
used by Dr. Potts was one-fourth to one-half of a grain three times 
a day ; the lx and 2x should be tried. It may act by improving the 
action of a weak heart, and giving it force to supply the senile areas 
in the brain with a normal amount of blood. 

The tremors of hysterical women are removed by scutellarin, 
asafoetida, and platina. If from fright, I have seen excellent results 
from aconite and ignatia. A patient of mine with tremors of the hands 
and head consulted Brown-Sequard in Paris. He prescribed a pill 
of the extract of cannabis indica one-eighth of a grain, phosphide of 
zinc one-tenth of a grain. She improved for a time under its use, 
but it was only a palliative. 



DISEASES OF THE NERVOUS SYSTEM. 837 

Phosphide of zinc 2x has cured mercurial tremors ; several cases 
are on record. 

The tremor of insular sclerosis is not amenable to any treatment 
yet discovered. Hammond recommends chloride of barium (baryta 
mur.) in one-tenth of a grain doses, but no actual cures have been 
reported. Phosphide of zinc and argentum muriate have been recom- 
mended. 

The eye tremors (rapid oscillary movements of the eyeballs, nys- 
tagmus) will be benefited by agaricus, if by any medicine. 

The percenta (nerve vibration) has proved of benefit in several 
cases. The application should be with the small point, over the 
tendons on top of foot near base of each toe, over nerve behind each 
maleolus, over radial nerve at wrist and ulnar at elbow, of each arm. 
With large plate over sole of foot and along each side of spinous 
processes. Applications should be made daily. 



CHOREA. 

Definition (St. Vitus dance). — May be in general terms defined 
as a disease of incoordination. Whatever the primal cause is, this 
term expresses the symptoms. The commencement may be so slight 
as to attract no notice. I have often been the first to notice it in 
families under my observation. A slight exaggerated wink of one 
eyelid, a twitch in the lips, or in a single muscle on one side of the 
face, is often the first symptom, which may persist for months before 
it extends to other muscles. In fully developed chorea, the patient 
is a most pitiable object. He cannot exercise any voluntary move- 
ment, and the convulsive motions are so severe as to prevent walking 
or standing. He is violently jerked in all directions, breaking bones, 
and bruising the tissues. The mind is usually affected from the first, 
and in the worst cases an almost idiotic state is present. There is a 
kemi-chorea where the spasmodic movements are confined to one side ; 
a chorea paralytica, where the paralyzed side is affected ; and a p>ost- 
paralytic chorea, when the spasmodic movements set in after a paral- 
ysis ; this last resembles paralysis agitans. It has been claimed by 
some authorities that many, if not the majority, of cases are caused 
by rheumatism. Others claim that the initial irritation commences 



838 THE PRACTICE OF MEDICINE. 

in the eyes, an u eye-strain." I have observed that a majority of all 
my cases occurred just before puberty. 

Fright is a common cause. Any sudden mental shock may excite 
the disease. It is often caused by worms in the intestines. Dr. H. 
C. Wood, in the " Therapeutic Gazette," 1885, mentions an intract- 
able case that nearly destroyed life, but which ceased on the expul- 
sion of a tape-worm. Another violent case was immediately arrested 
by the removal of lumbrici. 

The cause may be peripheral. A case of chorea which had lasted 
two years was cured by removing the roots of a tooth. Another of 
six-months duration was cured by the removal of a neuroma from 
the foot. 

Chorea may arise from organic disease of the brain, and is then 
incurable. It may arise from functional derangement of the brain, 
and is then curable. It may be caused by organic or functional dis- 
ease of the spinal cord. It may be epidemic, or the result of irrita- 
tion. In several instances I have known a school broken up by one 
choreic child, all the rest involuntarily imitating his spasmodic move- 
ments. It is impossible in some cases to distinguish chorea from 
hysteria. It occurs frequently in animals, especially in highly domesti- 
cated breeds of dogs and cats. 

The diagnosis of chorea from paralysis agitans, epilepsy, locomotor 
ataxia, cerebral and spinal scleroses, should be studied. 

A knowledge of the cause of the disease may enable us to make 
a quicker cure, by removing such cause. It may aid us in the selec- 
tion of the remedy in some cases. But as in most diseases, our real 
curative agents are selected by the resemblance of their symptoms to 
those of the disease ; a correct diagnosis of the pathological cause is 
not necessary. 

Treatment. — The surroundings of the patient should be made 
favorable to quiet of body and mind. A child or young person should 
be taken out of school until cured ; it should not be under any excite- 
ment or see anyone with the same disease. It should not be talked 
about, or attention called to its movements, in its presence. It occurs 
in both plethoric and anaemic subjects. 

Of all medicines arsenic is credited with the greatest number 
of cures. It is singular that Hart in his " Nervous Diseases " does 
not mention it. It is more singular that Lilienthal does not men- 



DISEASES OF THE HEART. 839 

tion it. Hughes barely alludes to it. On the contrary, the old 
school considers it, as Hammond declares, " almost specific" Other 
authorities are equally confident of its value. There are several pro- 
prietary nostrums which are successful in the cure of chorea. All 
contain arsenic, as I know by analyses, and by watching their effects 
when taken too long. The pathogenesis of arsenic abounds with 
symptoms simulating all kinds of nervous diseases. Why then have 
our school ignored it? I cannot answer the question. But I know 
that my success in the treatment of chorea was indifferent until I 
used it. 

The only reason why arsenic is not put down in our text-books 
may be, that it will not cure in the dilutions above the second. But 
this should not be a valid reason. Homeopathy is not a matter of 
dose, but of law, and if a drug like arsenic cures only in material 
doses, it is as much homeopathic as if the cure were made by the 
200th. I do not prescribe the heroic doses advised by those who 
direct it to be given until it causes gastric irritation and puffiness 
of the face. They advise for a child five drops of Fowler's solution 
after meals, increasing the dose one drop each day until the above 
symptom appears. I commence with one drop, in water, after each 
meal. For some reason this preparation seems to act better than any 
other. I increase one drop a day for ten days, then decrease for 
another ten days. If at the end of the twenty days no improvement 
appears, I think it is useless. 

Dr. Radcliff e, of England, and Dr. J. Lewis Smith, of this country, 
introduced the method of giving it by hypodermatic injection. Dr. 
Hammond says he uses it in that manner in all obstinate cases. He 
warns against improper methods of using the injections. He says it 
will cause abscesses and painful cutaneous inflammation. He says 
the safest location is on the front of the forearm, about midway be- 
tween the wrist and elbow. "Here the skin is loose and can easily 
be lifted up by the thumb and finger from the tissues below. The 
arsenic should be deposited just under the skin in the cellular tissue, 
and not in the substance of the muscle or skin. The point of the 
syringe should be carried just through the skin and then for half an 
inch parallel to the face of the arm, and the injection made slowly." 
He advises the arsenic to be diluted one-half with glycerine. He 
thinks the reason why this method is more successful is that the dose 



840 THE PRACTICE OF MEDICINE. 

can be much larger without causing arsenical poisoning. He declares 
that thirty-five drops can be given every day with impunity, and re- 
ports cases which had resisted all other drugs cured in a short time 
by these large doses, without any unpleasant arsenical symptoms. In 
acute cases of mild chorea, he says he has cured with three drops 
of Fowler's solution every other day, hypodermatically. If we fail 
with arsenic internally, and with other medicines, we should insist 
on trying this method. 

The bromides were at one time very extensively used in chorea, 
but they have been abandoned on account of the depression they 
caused. Only one, the bromide of camphor, is still used. In France 
it is highly valued, especially in women and female children. One 
remarkable case quoted by Hart was cured by one grain morning 
and night. I have cured several cases in women who were very 
emotional, and when chorea was caused by mental shock. 

Strychnine should be an excellent remedy in paralytic chorea in 
which the irregular movements are confined to the paralyzed side. If 
strychnine is indicated for the hemiplegia, it will remove the attend- 
ant chorea. 

Dr. Delamater cured with phosphate of strychnine a case of gen- 
eral chorea in a boy. He diagnosed the case as caused by anaemia 
of the antero-lateral column of the spinal cord. Nux and strychnine 
are indicated in that condition. In a few cases when I did not get 
favorable results from arsenic, it occurred to me that there might be 
a paralytic complication. This led me to try the arsenite of strych- 
nine 2x, and the results were all that I anticipated. This preparation 
has taken a high position as a cerebro-spinal remedy when there is 
anaemia of the motor column of the cord. 

Cuprum is a typical cerebro-spinal remedy. The choreic move- 
ments are characteristic. They appear to start in the fingers and 
toes and spread to the muscles of the limbs. The patients are better 
when lying down and when asleep, although the sleep is not entirely 
free from choreic movements ; the muscles of the throat are affected, 
causing dread of suffocation, and difficult deglutition. As taught by 
Rademacher, under certain circumstances copper appears to enrich 
the blood, like iron. If your cases of chorea are chlorotic, it is an 
additional indication for copper. If cuprum fails, try the arsenite 



DISEASES OF THE NERVOUS SYSTEM. 841 

of copper, which in my hands has cured two cases. Tablets of the 
lx or 2x ; one after meals and at bedtime. 

Cimicifuga has enjoyed a very extensive reputation in the treat- 
ment of chorea. Where we consider its profound sedative effect on 
the cerebro-spinal and sympathetic system, also its great value in 
rheumatism, we can account for that reputation. Any medicine which 
gains a purely empirical reputation among the aborigines and people 
of a new country must certainly have some specific virtues. From 
the earliest period this plant has had among the people and the early 
" Botanic Physicians " a reputation for the cure of chorea. From 
them it was taken up by the regular school. It is useful both in 
"fright chorea" and in many cases of chorea appearing just before 
or at puberty, in girls. Cimicifuga freely given will bring on the 
menses, after which the chorea will improve. It will cure chorea in 
older girls, when it appears only before and during the menses. Cases 
are on record in which chorea appeared only during pregnancy. 
Cimicifuga has benefitted many such cases. 

If melancholia, sleeplessness, and a wearing pain in the left infra- 
mammary region are present, this remedy is specially indicated. 

The dictum of Eclectics is, that before curative results appear, 
the patient must feel the effects of this drug in the head, a sense of 
tightness and expansive pain, but this is not necessary, although the 
curative dose of five to ten drops of the tincture, three times a day, 
often causes slight headaches. The active principle, cimicifugin, 
sometimes called " macrotin," is quite as efficient and more conven- 
ient, for a tablet of the lx, containing one-tenth of a grain, is equal 
to five drops of the tincture. 

Scutellarin has about the same influence over the motor nervous 
system as cimicifuga, but it acts more on the gray matter of the brain, 
and causes exhilaration rather than melancholy. For chorea from 
overstudy in children, or worry in women with obstinate insomnia, 
this remedy ought to be useful in the lowest triturations. (Cypri- 
pedin is useful in the same conditions.) 

Gelsemium is praised by C. L. Gregory, M.D., of Yreka, Cal., 
in the following article . 

€t I would like to call the attention of the profession to the use of 
gelsemium in chorea. I have been using this remedy during the 



842 THE PRACTICE OF MEDICINE. 

past six years in these cases, and have yet to record my first failure 
to cure. I was led to try it in an obstinate case of this disease, 
which had resisted every remedy exhibited, by reading an article in 
some medical journal, the name of which is not now remembered, 
claiming that it would cure chorea. I had tried rest, the milk diet 
and all the more prominently mentioned drugs, including a six weeks' 
use of Fowler's solution, without the least benefit, and I was greatly 
puzzled to decide what to do next. The case was a thirteen-year-old 
girl ; the movements were exceedingly annoying, interfering with 
rest and nourishment to such an extent that I feared she would not 
recover. Her heart was much weakened, and she was having a slow 
fever, tending toward the typhoid type. I put her on five-drop doses 
of tincture gelsemium every four hours, using it alone. In forty- 
eight hours there was perceptible improvement, and in ten days she 
was on the high road to recovery. In one month she seemed as well 
as ever, and has remained so, with one exception, to the present 
time. Three years ago she again showed symptoms of chorea, when 
I promptly placed her on three-drop doses of the gelsemium, and in 
two weeks she was again well. In her first attack, I gradually 
reduced the dose to one drop three times a day. 

" During the past six years I have treated eighteen cases of 
chorea with gelsemium alone, and without a failure. Two cases 
were girls who have since married, and in each instance have had a 
second and third attack, which was promptly controlled by the gel- 
semium, when pregnant with the first and second child. One of 
them has had a fourth and severe attack but recently, which was 
also cured in less than two weeks by the gelsemium. I do not now 
insist on rest, diet, etc., but depend wholly on this one remedy. I 
use a strong tincture made from the green or recently dried root, 
and I insist that the preparation must be good. No muddy fluid 
extract or tincture made from the dried-out and stale roots will 
answer the purpose. 

" I think it is a remedy well worth extended trial, but my expe- 
rience with it has been too limited to give more than a hint of its 
value. Doubtless there are many cases which it will not cure, but 
1 am inclined to think that if a first-class preparation of the green 
or very recently dried root is used, it will promptly cure a majority 
of them. I much prefer it to Fowler's solution." 



DISEASES OF THE NERVOUS SYSTEM. 843 

Dr. Hugo Lcewenthal quotes the statement of Dujardin-Beaumetz, 
that exalgine is not only an anodyne, but also acts upon the cerebro- 
spinal nervous system, and has a favorable effect upon convulsive 
conditions. 

Lcewenthal has tried it, and reports thirty-five choreic patients 
treated by him with exalgine during 1891. The doses were three 
grains three times a day, in some cases increased to five times a day, 
so that the amount given in a day never exceeded fifteen grains, nor 
fell below nine grains, except in the case of a three-year-old boy, who 
was given one and one-half grains three times a day. The powder 
was administered in sweetened warm water. The patients ranged from 
three to eighteen years of age. In some cases the chorea was light, 
in others quite severe. In general the result was satisfactory. Light 
cases were quickly cured; severe ones required a longer time. The 
duration of the cure varied from eight days to four months. Two 
boys who had slight attacks were cured in eight days. The average 
duration was from five to six weeks. 

Improvement was noted in some cases after taking twelve powders, 
or thirty-six grains ; but in most cases it was not until after seventy- 
five or ninety grains had been taken. The smallest amount given 
was to an eight-year-old boy, who took thirty-six grains in a week, 
and was dismissed cured. 

Along with the good action of exalgine, unfavorable symptoms 
were also noted. Ringing in the ears, intoxication, motes before the 
eyes, vomiting, increase of existing pain, headache, and cyanosis, 
which had already been noted by Rabow, Heinz, Cahn and Stepp, 
Gaudineau, Binet, Bokenham, and Jones. The last two also noted 
one case in which there were symptoms of poisoning. This depends 
upon the size of the doses and a protracted use of exalgine. Direct 
symptoms of poisoning Lcewenthal did not see. In every instance, 
upon the appearance of an unfavorable symptom, he at once suspended 
the use of exalgine. The small doses given could be continued for 
months. 

The bad results which he himself noted were nausea, once ; vom- 
iting, four times ; weariness, twice ; headache, twice ; vertigo, once ; 
vertigo, numbness, and vomiting, once ; jaundice, three times. 

As far as known, these are the first cases of jaundice following the 
use of exalgine to be reported. Cyanosis of the lips was noted once. 



844 THE PRACTICE OF MEDICINE. 

It must not be inferred from this list of bad results that the bene- 
ficial results of exalgine are cast in the shade. On the contrary, the 
exalgine was satisfactory in the majority of cases, although no spe- 
cific action in the cure of chorea can be claimed for it. The urine 
was examined occasionally. Once it had a brown color, tinged with 
green (this was not a patient with jaundice). Albumin and sugar 
were not found. The blood was frequently examined under the mi- 
croscope, but nothing abnormal was found. 

Hyoscyamus causes disorders of coordination to a greater extent 
than any other drug. Body and mind both seem to suffer from irreg- 
ular and involuntary motor irritability. Many cures of chorea are 
recorded due to this drug, but none so remarkable as the following, 
with the alkaloid hyoscy amine. 

Da Costa described the following as the worst case of chorea that 
he had ever seen. The patient was a boy about eleven years old, 
pale and weakly, and said by his friends to have always been nervous. 
Four weeks before the date when he was admitted (on the 14th of 
December) he had an attack of acute rheumatism, which involved 
all the larger joints of his body. The rheumatism lasted about three 
weeks, but as it declined choreic symptoms began to be manifested. 
His hands and arms were first affected, and afterwards his legs. 
When admitted he was actually unable to walk ; he was even unable 
to feed himself, and seemed in risk of starvation. He was wretchedly 
weak and emaciated. He could perform no coordinated movements 
with his arms or legs, and unless there was always somebody about 
to give him a drink of water or food he would have perished. This 
was not due to actual want of power in the muscles, but to the im- 
possibility of performing any voluntary act lequiring coordinated 
movements ; but when food was placed in his mouth deglutition was 
readily accomplished. When admitted he could not articulate a word. 
He could not put out his tongue, although he could open his mouth 
and move his jaws, but he could not ask for food. His expression 
was that of an imbecile, and he was reduced to a mere shadow. At 
first his arms and legs were constantly moving, both sides being 
equally affected. No power of grasp existed in his hands, though 
sensation did not seem impaired. He complained of pain when he 
was pinched. The patella reflex was normal, and not exaggerated. 
No marked change in the electrical reaction was observed. His pupils 



DISEASES OF THE NERVOUS SYSTEM. 845 

were very much dilated ; his pulse was only fifty per minute, and 
rather weak; there was a systolic mitral murmur heard at the apex. 
These involuntary muscular movements did not continue at night, 
when he was asleep. His urine had been examined, but neither albu- 
men nor sugar was detected. His bowels tended to constipation. 
The ordinary remedies for chorea act slowly ; arsenic, though one of 
the best of our therapeutic agents for this disorder, acts slowly; it 
takes time, and the loss of time here might be fatal. Dr. Da Costa 
then recalled a case of tremor which he had seen rapidly influenced 
by hyoscyamine, the active principle of hyoscyamus niger. He con- 
cluded to try it here. He ordered him to take l-200th of a grain 
to begin with, a decided dose for a boy of his age ; but not finding 
a marked influence, he concluded that it would be advisable to increase 
the dose to 1-1 00th of a grain, given three times a day. Now the 
effect was admirable. From the first few days the boy began to 
improve, and at this time he had some dryness of the throat and 
wanted his mouth frequently moistened. He soon became brighter 
in his mind ; he took more interest in what was going on ; he moved 
voluntarily in bed, and tried to help himself to food. His voice also 
returned and he left his bed and began walking about the ward. After 
this his recovery was rapid and uninterrupted. He has had no other 
treatment than the hyoscyamine, and he has now so much improved, 
though he is still somewhat pale, that he may be looked upon as having 
recovered. He can sit quietly ; he has power over his hands, both in 
coordination and in grasp, although his grasp is still a little feeble. 
His pupils are dilated, though not much. The systolic apex murmur 
persists — it is a chronic mitral regurgitant murmur. In every other 
respect the boy is nearly well. 

For many years I have used hyoscyamine and hyoscine in mental 
and nervous disorders. Where they are indicated, their action is 
greatly superior to the tincture of the crude drug. 

Strammonium, owing to its close relationship to hyoscyamus, 
ought to be useful in chorea, but we have no direct proof of it. 
Possibly its alkaloid, daturin, may prove effectual. I do not believe 
that either belladonna or solanum are homeopathic to chorea. Atro- 
pin has been recommended for it, but I can find no positive evidence 
of its value. 

In relation to tarantula and mygale, I have serious doubts of 



846 THE PRACTICE OF MEDICINE. 

their value, notwithstanding the reports by Drs. Firmont and Goudy 
of cases cured by the former ; and those of Dr. Spooner and Blake 
of cures by the latter. I have used them both when apparently indi- 
cated, but got no good effects. I am equally in doubt about the cure 
of a severe case of chorea with phosphoric acid reported by Hempel. 
The symptoms disappeared under its use, but why? Phosphoric 
acid produces no choreic symptoms. It could not have been homeo- 
pathic. But as Hempel gave large doses of the acid it probably 
acted solely as a tonic to the nerve centres. This leads me to observe 
that in cases of chorea in poorly nourished children, pale and ema- 
ciated, the hypophosphites greatly aid the action of specific remedies. 
An emulsion of cod liver oil with hypophosphites is almost indis- 
pensable when such children will not eat fatty food. 

In robust plethoric girls, who often have chorea, there is no drug 
that equals veratrum viride. Some of the most violent cases have 
yielded to its influence. The spasmodic movements almost verge on 
tetanus and opistholonus. The heart's action is very violent and per- 
haps spasmodic. (Dose, one to five drops every three hours.) 

Agaricus muscarius has cured many cases of chorea when accompa- 
nied by symptoms of cerebral irritation. A study of the provings will 
show how close a similimum it is to the most bizarre and violent cases. 

When we are sure that the disease is caused by worms, after 
ascertaining if possible the species, we should expel them. For tape 
worms, use felix mas, naphthaline five grains three times a day, and 
other remedies mentioned under intestinal parasites. Silica and 
cina have made cures in such cases when caused by round worms. 
Santonine lx is often quite efficient. 

In hospitals there have been cases so violent that the main treat- 
ment has been to produce constant sleep for many days. In some 
cases chloral, given in doses of ten to twenty grains every two hours 
for a week or more, has brought about a cure. 

Chloroform, used almost continuously, has been resorted to with 
alleged good results. 

" Dr. Gross, of Regensberg, finds argentum nitricum, 2nd to 4th 
trituration — probably decimal — more effective in chorea than any 
of our ordinary remedies, and relates four cases illustrative of its 
powers (AIL Horn. Zeit., vol. lxiv., No. 24.)" The cases cured by 
this drug were probably of spinal origin. 



DISEASES OF THE NERVOUS SYSTEM. 847 

CARDIAC -CHOREA. 

This is not a disease of itself, but a state of the heart associated 
with chorea. I have seen several undoubted cases in which the 
choreic movements were first observed in the heart. Its movements 
were spasmodic, irregular, and the palpitation unlike other palpita- 
tions. The beats of the heart remind one of jumps, leaps, and other 
choreic motions. It may be rheumatic, but is probably neurotic in 
most cases. In other instances it appears during an attack of rheu- 
matism. 

It may be caused by worms. In all these varieties, the principal 
indicated remedies are veratrum album, veratrum viride, and spi- 
gelia. 

Spigelia has been ignored in chorea, but I am satisfied that it 
may prove useful in other than cardiac cases. For the symptoms 
mentioned above I consider spigelia specific (in the 3d or 6th). 

Veratrum album and veratrum viride are indicated when the 
movements are not alone irregular, but rather forcible and spas- 
modic. 

Cactus may prove an excellent remedy. The palpitations caused 
by it are singularly irregular. 

Physostigma is a remedy of great value in these cases, where the 
action of the heart is exceedingly irregular and tumultuous, the lx 
— a tablet every two hours. In some cases the 3x three times a 
day, and in some cases it has seemed necessary to use from one to 
three-drop doses from two to four hours apart. 

The nutrition of the patient should always be carefully looked 
after in all cases of chorea. 



CHOREA IN PREGNANCY. 

Chorea, which is a rare complication of pregnancy, affects primi- 
parae by preference, particularly those possessing an hereditary pre- 
disposition. Barnes was able to collect only fifty-six, and Fehling 1 
only twelve additional cases from the whole domain of obstetrical 
literature. 

According to Goodell, the choreic movements are of reflex nature, 
and are referable to impaired nutrition of the central nervous system, 



848 THE PRACTICE OF MEDICINE. 

incident to the hydraemia of pregnancy. The association of chorea 
and organic cardiac disease has been frequently observed, and the 
discovery in certain cases of fibrous vegetations upon the mitral and 
aortic valves accounts for the assumption, by some authors, of em- 
bolism as a cause of chorea. Barnes discountenances this view, and 
calls attention to the probable causative agency of myelitis. Terror 
and other intense emotions may act as exciting causes of chorea. 
Choreic movements occurring in pregnancy do not differ from those 
attending the disease in the unimpregnated state. They are usually 
bilateral. In most cases the muscular contractions manifest them- 
selves in the earlier months of pregnancy, and continue until delivery 
is accomplished. In rare instances they are arrested at the begin- 
ning of parturition. In still more exceptional cases the contractions 
may either cease before delivery or persist during the post-partum 
state. Transitory albuminuria and diabetes mellitus are occasional 
unexplained complications of chorea gravidarum, and the phosphates 
and urates of the urine are present in abnormal abundance. Abor- 
tion and premature delivery, due to the repeated succussion of the 
uterus, are of very frequent occurrence. 

Chorea exerts a prejudicial influence upon the . course of preg- 
nancy, having interrupted it in about one-half of the recorded cases. 
Death of the mother resulted in seventeen of the fifty-six cases col- 
lected by Barnes. The fatal termination was usually referable to 
the exhaustion consequent upon protracted muscular exertion, or to 
hemiplegia secondary to grave cerebral or spinal lesions. The life 
of the child is less frequently sacrificed, but it is itself often affected 
with chorea. 

The following conclusions, arrived at by Dr. Lever twenty years 
ago, fully represent the present state of our knowledge in respect to 
most of the points mentioned. " In conclusion," says this writer, 
" I venture to submit the following propositions : (1) That preg- 
nancy is occasionally associated with chorea or convulsive move- 
ments ; with paralysis of various parts of the body, of the extrem- 
ities and of the nerves of special sense ; and with mania. (2) That 
the varying symptoms of such complications may be produced at 
any period of pregnancy, but when produced, although modified by 
treatment, are rarely removed during the existence of gravidity. (3) 
That the patients in whom these complications exist are women of a 



DISEASES OF THE NERVOUS SYSTEM. 849 

highly nervous temperament, of great irritability, or whose constitu- 
tional powers have been reduced by some long-continued but serious 
cause of exhaustion. Lastly : That although in most instances the 
symptoms will continue so long as pregnancy exists, yet in a major- 
ity of cases we are not justified in inducing a premature evacuation 
of the uterine contents." 

Treatment. — The treatment of the chorea of pregnancy requires 
some remedies not usually used in the non-pregnant. If we take it 
for granted that the choreic movements are of spinal origin, the chief 
remedies should be cimicifuga, ignatia, agaricus, cuprum, cuprum 
arseniosum, and vis cum album. I believe cimicifuga to be the most 
potent remedy. I have cured several cases with the tincture in five- 
drop doses every four hours, and with macrotin in one-tenth of a grain 
doses every three hours. It should be continued for weeks before we 
suspend its use, even if we see no improvement. The mental state 
indicating it is one of depression and melancholy. 

Ignatia is indicated in those choreic movements which resemble 
chorea but are due to reflex irritation, or have a mental origin, such 
as fright, hysteria, etc. The mental symptoms are important — the 
alternation of weeping moods with those of unnatural liveliness and 
joyousness ; the jerking and twitchings do not entirely cease during 
sleep. (Dose, 3x to 6x.) 

Agaricus has been found useful when there are illusions of sight 
and hearing. Gelsemium is of great value. 

Hyoscyamine or hyoscine are specific when in addition to choreic 
movements there is a general excess of motility, a constant desire to 
be in motion, especially at night, when there is ungovernable mental 
and bodily anxiety and restlessness. The dose should begin with one 
grain of the 3x trituration. If no improvement is observed in a few 
days give two or three grains — the dose to be repeated every four 
hours. The maximum dose is the 1-2 00th of a grain three times a 
day. Illusions of sight, such as seeing bugs, vermin, or hideous faces 
when the eyes are closed, horrible dreams with waking in a fright, 
or morbid jealousy, are special indications. When there is hydre- 
mia, paleness, oedema of the feet, and debility, arseniate of iron, 2x ; 
arsenite of copper, 3x ; or the arsenite of potassa, 2x, are invaluable 
remedies. The dose is one to five grains after meals. Yiscum album 
is especially indicated when with the chorea there are epileptiform 

54 



850 THE PRACTICE OF MEDICINE. 

paroxysms similar to uterine epilepsy. In very bad cases, when the 
movements are violent and convulsive, depriving the patient of rest 
and sleep day and night, do not hesitate to give ten grains of chloral 
with ten of bromide of soda every six hours until the patient is quiet. 
This has been known to prevent miscarriage and premature labor* 
In milder cases sulfonal, fifteen or twenty grains, given in hot water, 
will produce a restful sleep of eight or ten hours. Trional — seven 
to ten grains — will sometimes act favorably. Chloralamid will often 
act better than chloral. The patient should be kept quiet and free 
from all annoyance and irritation, and the use of tea, coffee, and beef 
be forbidden. 



EPILEPSY. 

Definition. — A disease characterised by paroxysms of more or 
less frequency and severity, during which consciousness is lost ; and 
which may or may not be marked by slight spasm, or partial or gen- 
eral convulsions ; or mental aberrations, or by all these circumstances 
collectively. The essential element of the epileptic paroxysm is loss 
of consciousness ; without that there can be no true epilepsy. 

Two varieties of the paroxysm itself are recognized ; the grand 
mal, and petit mal. In the former there is always violent convulsive 
action. In the latter, none — but in both there is loss of conscious- 
ness, varying from a few seconds to an hour. 

Hammond gives five varieties, one of which he calls thalmic, 
because there are simple hallucinations and loss of consciousness, and 
he believes the seat of irritation is in the optic thalmus. There is a 
variety called vaso-motor epilepsy, in which there is an arterial spasm, 
commencing in the fingers and toes and extending to the brain. It 
is like vaso-motor angina pectoris. A large proportion of cases of 
epilepsy belong to this variety. 

There is a reflex epilepsy, originating from a wound (traumatic); 
or from some organ — especially one of the reproductive system — an 
irritation transmitted to the convulsive centre in the brain. 

The " epileptic aura " is not present in all cases, and is so different 
in its character that an enumeration of the varieties would be difficult. 

The causes of epilepsy are legion ; nearly every disease of the 
brain has been found post-mortem, although sometimes no disease of 



DISEASES OF THE NERVOUS SYSTEM. 851 

either brain or cord is perceptible to the naked eye or the micro- 
scope. 

In these days when specialists control the treatment of all serious 
diseases of the nervous system, the general practitioner does not 
have them to deal with, but the milder and obscure forms of epilepsy 
often come under the physician's care. I can only relate my expe- 
rience with the latter and give a brief resume of the treatment 
adopted. 

Among the mild forms of petit mat are those cases that arise from 
over-study or mental depression, in which the only symptom is a sud- 
den, transient loss of consciousness, which may occur when talking, 
reading, walking, or working. There is a sudden cessation of motion, 
and a staring, vacant look, and whatever is in the hand drops. Many 
such cases have been cured by phosphoric acid, hyoscyamus, canna- 
bis indica, and agaricus — selected according to the causes, and the 
similarity of the symptoms. Another form generally occurs in chil- 
dren, and when not hereditary may arise from worms, teething, and 
other causes remote from the medulla, but transmitting an irritation 
to it. This variety manifests itself by sudden loss of consciousness 
with staring, flushed face, rigidity, and (in males) erection of the 
penis, and passes off with deep sighing and involuntary urination. 
There may be some twitching and trembling. This form is some- 
times caused by contracted and adherent prepuce, and requires dila- 
tion or circumcision. If from worms, naphthaline is better than 
santonine, in doses from one-tenth to two or five grains three times 
a day. It is one of the most effectual vermifuges we possess. San- 
tonine can be used, but in small doses (not more than one-tenth of 
a grain), and its effects must be carefully watched, for it has caused 
epileptic convulsions when given in large doses. If given when 
worms are supposed to be the cause it often cures the epileptiform 
seizures, even when worms are not present. The same observation 
applies to cina, chenopodium, tanacetum, and other worm-medicines. 
In cases resulting from stomach worms, scale pepsin in capsules, five 
grain doses from two to four hours apart, has frequently resulted in 
complete and permanent cure. I have cured several cases of petit 
mat in children with calcarea and silica, when the cause was sup- 
posed to be teething or worms. " Night terrors," or " night-mare," in 
children are epileptiform seizures, and " grinding of the teeth " often 



852 THE PRACTICE OF MEDICINE. 

arises from the same cause. In a family under my care two of the 
children have petit mal, one grand mal, and one suffered from vio- 
lent night terrors. This last, after getting some benefit from sola- 
num and hyoscyamus, was apparently cured by the bromide of gold 
8x. I once considered the bromide of camphor lx almost specific, 
but gold acts very much better in many cases. 

Cimicifuga lx has often cured night attacks of petit mal. Cuprum 
aceticum is also a valuable remedy. 

I have had but few cases in which I felt justified in pushing the 
use of the bromides to the extent of bromism. I was not satisfied 
with the result. It may be possible, as Hammond asserts, that he 
" is sure the bromic cachexia is favorable to the eradication of the 
epileptic tendency." He advises to produce bromism as soon as pos- 
sible. Few physicians are courageous enough to do this, and few 
patients will submit to it. The few radical cures obtained by the 
use of the bromides hardly warrant us to give it to that toxic extent. 
There is a variety of epileptiform disease termed menstrual epilepsy, 
in which the bromides, especially the bromide of camphor, is almost 
specific. The attack has hysterical features, and is often attended 
with erotism. This latter condition is generally attended with an 
intolerable itching and irritation of the genital surfaces, clitoris, vulva, 
and vagina. 

Such cases I have cured with bromide of potassium, ten grains 
every four hours, for three days before the menses ; also with ten 
grains of the lx and 2x trituration of the bromide of camphor given 
in the same manner. 

Hammond lately praises the bromide of zinc in epilepsy. His 
formula is : zinc, brom., one drachm ; simple syrup, one ounce. Dose, 
ten to thirty drops three times a day. This should be given largely 
diluted, as it often causes nausea and vomiting. He says it has suc- 
ceeded in arresting the paroxysms when other bromides have failed, 
and that it does not produce bromism, or the cachexia, even when 
given six months or more. The bromide of strontium may be better 
than the bromide of zinc, as it causes neither bromism nor any other 
disagreeable symptoms. This would seem to disprove his assertion 
that bromism was necessary. I cured one mild case with this bromide 
of zinc. The paroxysm came on after dinner regularly. Only one- 



DISEASES OF THE NERVOUS SYSTEM. 853 

tenth of a grain was prescribed, repeated before each meal. After 
a week there were no more attacks. 

Oenanthe crocata is probably of all known drugs the most home- 
opathic to epilepsy. A study of the cases of poisoning, in its patho- 
genesis, will prove this. My prediction in the last edition of " New 
Remedies " has been verified in many cases, in which the 3d and 6th 
has cured violent attacks of grand mat. 

The bromide of gold has lately attracted wide attention. Dr. 
Goulard, of Paris, was the first to use it. Ten years' experience with 
it convinced him that a large number of severe epilepsies may be 
cured by it. In typical migraine, which is a species of epilepsy, he 
has found it curative. He gives from one-sixth to one-twelfth of a 
grain three times a day. This dose will at first cause headache and 
irritability of temper, but is soon tolerated. I have not yet used it 
in grand mal, but have cured several cases of the mild form with the 
3x trituration, two grains three times a day. 

Our school claims to have cured epilepsy with belladonna, cuprum, 
argentum, cannabis indica, and indigo, selected according to the law 
of similia. Per contra, Hammond in his last edition says he has 
tried belladonna, nitrate of silver, indigo, cotyledon, digitalis, and the 
salts of copper, without producing the "least good effect," — but he 
gives large doses. 

Clinical cases of epilepsy cured by rana bufo, from Hering's 
Horn. Clinic. Dr. Saville was the first who used rana bufo and sala- 
maudra with success, not only in epilepsy, but also in paralysis, rabies, 
and somnambulism. He made his report to the Homeopathic Con- 
gress in Bordeaux, in the year 1854. Dr. Andriem and Dr. Tegdet 
followed his example, and also frequently used this remedy with suc- 
cess in epilepsy. The following short cases are given by Dr. Saville : 

" (1) A young man, set. eighteen, but of such delicate build as 
to look like fifteen, was afflicted with very frequent epileptic attacks. 
After bufo in diverse potencies, these attacks ceased and did not 
recur even after gross excesses. 

" (2) P. B., set. twenty- four, suffered since ten years with epi- 
lepsy. The attack of late came on about every two months. After 
having taken bufo in diverse potencies (from 1 to 6) he had only one 
slight attack. 



854 THE PRACTICE OF MEDICINE. 

" (3) Mrs. C, set. twenty-eight, married since nine years, mother 
of three children, of whom the youngest is three months, experienced 
the first attack of epilepsy two weeks after parturition, eight years 
ago. The attacks increased in frequency so that she now has two a 
a week. She is much emaciated, and bears the scar of a burn she 
received by falling into a fire during an epileptic attack. She 
received one drop of bufo in eight ounces of water, a teaspoonful 
every morning, and this was succeeded by the 1st to 6th potencies. 
The attacks ceased from the first day and did not come back. 

" (4) Dr. L. one day came into a village at the moment when 
several women bore another into a house, she having been seized 
with an epileptic attack in the street. By permission of the hus- 
band I gave her bufo 12, and the attacks failed to come back. 

" (5) Mrs. D. had epilepsy for ten years or more. Of late the 
attacks came on every second day and at the same time. Patient 
set. thirty-five, mother of three children ; is emaciated and looks 
miserable. She expected with certainty an attack next morning at 
6 o'clock, and wanted to wait the beginning before taking the med- 
icine. Dr. L. gave her a teaspoonful of the remedy at once, and 
advised her to take another at bedtime, and at five in the morning. 
Two weeks after, she reported that the expected attack did not 
occur, that she had taken the medicine regularly, and that she had 
had no attack since." 

In the Transactions of the American Institute, Dr. Holcombe 
reports seven cases treated by bufo 200, of which three failed to call 
again because a first amelioration was followed by further attacks. 

His fourth case was a woman of sixty, who had suffered from 
epilepsy since her thirtieth year. The attacks occurred once a week, 
always at night, and were followed by coma of several hours' duration. 
After taking bufo 200 no attack occurred for six months, and since 
then only two or three light ones. 

" A woman, set. thirty, was very much reduced, bodily and men- 
tally, by furious epileptic attacks, which supervened several times a 
week, which had been treated in vain by many physicians, and which 
had been pronounced incurable. I prescribed six pellets of bufo 200 
once a day. For five succeeding days she was free from attacks, and 
during that time her persistent headache vanished, and the cata- 
menia, which had ceased for a long time, reappeared ; her appetite 



DISEASES OF THE NERVOUS SYSTEM. 855 

was better, as well as the color of her face ; she had grown stouter 
and more vigorous ; her mental capacities also had improved. Ac- 
cording to last reports she had within one year only one or two light 
attacks. 

N. B. — This patient I never saw ; I treated her by letter, but 
the case seems to have created such an impression that a physician 
who formerly treated her wrote to me for homeopathic books and 
medicines, and consulted me about a brain affection with which he 
himself was afflicted, and two epileptic patients from the same town 
sought treatment from me. 

The other two cases were young men who had been afflicted with 
epilepsy for several years, and who averaged an attack every month. 
I commenced treatment by giving each a dose of bufo 200 every 
day, and one had not had an attack for ten, the other eight months." 

Although these reports are insufficient and convey no conviction 
of the general utility of the remedy, they yet seem to prove that 
bufo is destined to become of great service in the treatment of epi- 
lepsy. 

Gratiolet and Cloezer inoculated a sheep, a dog, and a cat with 
the virus. The symptoms produced were torpor, interrupted by vio- 
lent convulsions. A dissection disclosed general softening of the 
spinal matter, and the muscles were devoid of all irritability. Dr. 
Leydet used bufo also with success in softening of the brain." 

Notwithstanding the above report I am still in doubt as to the 
reality of the cures. 

I cannot believe that bufo, tarantula, or lachesis ever cured a 
case of true epilepsy. Nor do I believe the fabulous stories about 
the cures made by Boennenghausen with drugs selected with all pos- 
sible mechanical accuracy, and with a single dose of the 200th never 
repeated. They may be true notwithstanding my unbelief, but I fail 
to see how a drug can cure that has not in its pathogenesis a simil- 
imum of the epileptic spasm. 

There is one method which is worthy of attention, first used to 
modify the paroxysm, but lately as a curative agent — the inhalation 
of amyl nitrite on the appearance of any premonitory symptom, or 
the aura. It will positively arrest violent paroxysms if used in 
time, and greatly modify their recurrence. 

Glonoine (nitro-glycerine) has been of more value as a curative 



85Q THE PRACTICE OF MEDICINE. 

agent, especially in vaso-motor epilepsy. If a tablet, or disc, of 
l-100th or l-200th of a grain be placed on the tongue as soon as the 
fingers begin to get cold (the cold aura) it has time to arrest the 
progress of the vaso-motor spasm before it reaches the brain. It has 
lately been prescribed to be given regularly three or four times a 
day when the paroxysms were frequent — keeping the arteries relaxed 
nearly all the time, and has actually cured many bad cases. If its 
effects did not soon pass off — they last only two hours — the result 
would be better. 

The nitrite of sodium acts longer (one or two grains every six 
hours), and the cobalto-nitrite of potassium still longer. This last is 
given in doses of one-tenth to one-fourth of a grain three times a day* 

Somnambulism is a species of epilepsy. During the attack there 
is a state of unconsciousness. Any act the person may perform in 
that state is an unconscious act, even if the act is murder. I have 
had several curious cases. One in particular, a woman of middle age 
who, at irregular periods of a week or two, would spring out of bed 
in the night, and rush around the room, or go to a window and try 
to open it. No treatment has been of any avail, although hyoscyamus, 
strammonium, and gold have been faithfully tried. Another, a little 
girl five years old, who would spring suddenly out of bed and attempt 
to get out of the room. After other remedies were futile, she was 
cured by the bromide of gold, 3x. 

Epileptic delirium and insanity is a " fashion " just now, and is 
taken advantage of by criminal lawyers to clear their clients from 
the penalty of murder, manslaughter, or any other crime. That such 
a condition does exist is the opinion of all alienists. 

Trosseau uses the following language : " It may be said, almost 
without fear of making a mistake, that if a man suddenly commits a 
murder, without any previous intellectual disturbance, without having 
up to that time shown any symptoms of insanity, and if not under 
the influence of passion or alcohol or any other poisonous substance, 
it may be said that the man is afflicted with epilepsy, and that he has 
had a fit, or an attack of epileptic vertigo." Trosseau should have 
omitted the word " passion," for a fit of passion may bring on an 
attack of epileptic insanity or fury. Persons subject to such attacks 
should be consigned to a lunatic asylum, instead of being turned loose 
upon the public. 



DISEASES OF THE NERVOUS SYSTEM. 857 

Women are especially subject to attacks which may be called 
hysteri co -epilepsy. One such case I cured with hyoscine ; she was 
apparently in perfect physical health. Her husband informed me 
they had been married a year and had been very happy until a few 
weeks before I saw her, when she became irritable and suspicious at 
times. For weeks she would appear perfectly natural, happy, and 
amiable, then suddenly she would have suspicions that certain persons 
were conspiring to alienate the affections of her husband. She had 
no doubt of his fidelity or affection for her. If she saw with hiui 
any of the persons she suspected, she would become enraged to such 
an extent that she was a fury, and would bite, scratch, and attack 
her husband with violence, and use the most abusive language. After 
the attack she had no remembrance of her actions, which were always 
followed by hysterical weeping and stupor. Her uncle was an epi- 
leptic, and in an asylum, and her sister had hysterico-epilepsy. I 
prescribed l-500thof a grain of hydrobromate of hyoscine four times 
a day. She had but one more attack, and informed me a month after- 
wards that all her delusions had vanished. If she had killed her 
husband in one of those attacks she should have been held irrespon- 
sible. 



HYSTERIA. 

It is impossible to define this protean nervous disorder. The old 
name is misleading, as it is not a disease emanating alone from the 
womb or the sexual organs, for men are the victims of it, as well as 
infants and children before puberty. Hammond's observation is that 
" hysteria essentially consists in the predominance of the emotions 
over the intellect, and especially over the will." 

It can imitate almost every disease named in our vocabulary, even 
some organic diseases. To attempt the treatment based on its symp- 
toms of the mind or body is usually futile. We should seek to find 
the cause. In women most cases do arise from some fault in the 
genital organs or functions, but often the most searching examina- 
tion of all the organs fails to find the slightest deviation from a 
healthy standard. A girl or young woman may have hysteria in an 
aggravated form all her life until she marries, when it manifests 
itself no more ; but if she has no children, it reappears after a few 



858 THE PRACTICE OF MEDICINE. 

years, or when she becomes a widow. In such cases it would seem 
to depend on unsatisfied physiological demands. But some women 
who are very prolific have hysteria all their lives, even after the 
climacteric. 

I believe the real seat of hysteria is in the brain. It may be a 
diathesis, latent, perhaps, until aroused by some psychical cause, or 
some local disease. Many of the domestic animals have hysteria, 
especially mares. Balkiness is a kind of hysteria. 

The treatment of hysteria requires the highest diagnostic acumen 
combined with consummate tact. The physician who depends upon 
medicines alone will have poor success. He must first gain the con- 
fidence of his patient. She must believe that he knows exactly what 
is the matter with her, and that he can cure her. If the physician 
acts hesitatingly, or seems in doubt, he can do nothing. Most hys- 
terical patients are conscious of what is said and done around them. 
Consequently what the physician says when the woman seems uncon- 
scious should be carefully weighed. 

We can take advantage of this, and by allowing the patient to 
suppose we think her unconscious we can say things that may greatly 
assist in her cure. In one particularly intractable case, where I 
suspected the woman was playing on her husband's sympathies too 
much, I said to him, during one of her paroxysms, that " if this thing 
continues much longer we shall have to send her to an asylum." 
After that she had but one or two slight paroxysms, and doubtless 
pondered seriously on the matter, for she was soon restored to her 
usual health. 

Some women have such a morbid craving for sympathy that they 
actually invite hysterical attacks in order to gain by it. Physicians 
should be very cautious about showing more than professional sym- 
pathy. Dr. Oliver Wendell Holmes, in one of his novels (" The 
Guardian Angel"), gives a very happy illustration of this. Nor 
should the nurses and attendants show too much sympathy. I doubt 
if women in hysterics suffer any actual pain. Nor do I believe there 
is much if any danger of injury from their violent contortions. If 
possible, I insist that the patient be let alone, for I am sure that re- 
straining her movements aggravates the paroxysms. I have never 
yet known a patient to be injured if let alone. I believe nearly all 
hysterics while in a paroxysm would do better if placed upon the 



DISEASES OF THE NERVOUS SYSTEM. 859 

floor of a room and left alone, with the impression that they are to 
remain alone, until they recover. Often when 1 have ordered this 
to be done, the woman came out of the paroxysm before there was 
time to carry the order into effect. I have known a prolonged par- 
oxysm to be arrested by the arrival of a telegram, or by the sudden 
illness of one of her children. I knew a young lady who went into 
the most violent hysterical convulsions I ever saw, recover directly 
on the arrival of her lover, whom she feared was unfaithful. An- 
other married woman recovered quickly after many days of convul- 
sion, when she thought she saw her husband flirting with her cousin. 

M. Charcot gives a remarkable ease of a woman who had been 
in the hospital for four years with hysterical contractions of the 
flexons of the feet and tetanic stiffness of the legs. For some in- 
subordination he threatened to send her away from the hospital. 
The next morning the contractions had all disappeared. 

During the paroxysms I have found ether and chloroform given 
freely to be the best treatment. Kepeat the anaesthesia again and 
again until the patient remains quiet. Chloroform never injured a 
woman in hysterics. For mild attacks they can be given internally, 
of ether a teaspoonful, of chloroform five drops in a spoonful of 
water. In some intractable cases I have injected hyoscine — one 
one-hundredth of a grain, with surprisingly good results. 

In my country practice I had an eclectic colleague who relied 
altogether on lobelia. He gave a full emetic dose, and I have known 
a paroxysm cease for good as soon as vomiting and relaxation set in. 
I once gave apomorphine for the same purpose, one-eighth of a grain, 
with the same result. 

The influence of diversion is a great factor in such cases. The 
old nurse's practice of burning feathers under the nose of hysterics 
was a good one. It acted as does the placing of mud or filth in the 
mouth of a balky horse. Dashing water in the face sometimes arrests 
a paroxysm, but the effect is not sustained enough. In prisons they 
place the women under a prolonged shower-bath, which always puts 
an end to the paroxysm. The inhalation of amyl nitrite is often 
efficient. 

The medicines recommended for the cure of hysteria are legion 
and but few of them are of any value. 

The medicines selected for the radical treatment of the status 



860 THE PRACTICE OF MEDICINE. 

hystericus must be those that are capable of causing a similar status 
with similar symptoms. There are certain drugs that may be called 
hysterical drugs. Gurnsey (Obstetrics) recommends and gives pre- 
sumed indications for forty medicines. Of these only ten are of real 
value. The others have symptoms like hysteria, but cannot cause 
the status. The true hysteria remedies are asafoetida, aurum, coc- 
culus, coffea, cajuput, camphor and bromide of camphor, castoreum, 
cypripedium, hyoscyamus, ignatia, moschus, nux-moschata, platina, 
Scutellaria, valerian, sumbul, simplocarpus, and zinc. 

I will mention only those which I have found useful, and leave 
the reader to study the others. 

Asafoetida is one of the most useful, when given for weeks and 
often for months. It appears to remove the exaggerated sensibility 
of the nervous system, acting principally on the great sympathetic. 
It is most applicable to women of robust physique, full-blooded, pas- 
sionate, going to extremes of emotions of joy and melancholy, with 
tendency to local congestions. The convulsions are almost epileptic, 
and often similar to apoplexy. I give one or two grains before each 
meal The eminent Dr. Goodell, of Philadelphia, gives a pill of 
which asafoetida is the chief ingredient. It has a great reputation 
with the old school. In each pill is — ext. sumbul, one grain ; asa- 
foetida, two grains ; sulphate of iron, one grain ; arsenious acid, one- 
fortieth of a grain. One pill after each meal. This combination 
will shock many of our school, but its powerful tonic properties can- 
not be denied. 

Dunham with a master-hand gives a differential diagnosis between 
asafoetida and platina. They are quite antagonistic in their symptoms, 
platina being useful for spare, pale, thin-blooded women, who are 
melancholy, with profuse menses, and of violent passions. I have 
always been disappointed in platina. It has never cured hysteria 
when apparently indicated, although I have given it in the 3d, 6th, 
and 30th. 

Aurum has given me better results. It is more like asafoetida 
than like platina. The chief indications are the exhilaration, followed 
by suicidal melancholy ; the ovarian irritation ; the scanty or very 
profuse menses ; the desire for alcohol, and the great irritability of 
mind and body. 

The bromides are always given by the old school, and often their 



DISEASES OF THE NERVOUS SYSTEM. 861 

good effects are undeniable. The newly-discovered bromide of stron- 
tium, which is declared quite innocuous, should be tried, as it does 
not cause bromism. Hammond prefers the mono-bromide of camphor. 
In several cases it has acted very satisfactorily. I have not given 
the large doses recommended, finding the lx or 2x quite strong enough, 
if given every hour or three times a day, as the case demands. 

Castoreum is rarely used, but in my early practice it cured two 
bad cases for me. Its provings show it to have many hysterical symp- 
toms. Jorg declares it inert, and that on healthy persons it had no 
effect. But our provings show otherwise. Richter says that even in 
small doses it cures true hysteria, i. e., from uterine irritation. He 
advises small doses ; I used the 3d trituration. 

Cocculus is useful in some cases of hysterical vomiting, when there 
is present its peculiar dyspnoea. 

Hammond and Pavit claim to have cured obstinate hysterical 
vomiting with the valerianate of caffeine. I have never used it, but 
I have arrested such vomiting, and the vomiting of pregnancy with 
hysterical symptoms with cocaine, one-twentieth of a grain every hour. 

Moschus is only useful, like camphor, in hysterical collapse, with 
spasm of the larynx. Glonoine and amyl have a quicker and better 
effect, in vaso-motor complications. 

I have sometimes seen good effects from valerian in the paroxysm ; 
and from viburnum, when it occurred from dysmenorrhoea. One 
case of hysterical headache or violent hemicrania, always ending in 
hysterical spasms, was cured with valerianate of zinc, one grain (in 
pills), three times a day. 

Ignatia is a splendid remedy in purely emotional cases with se- 
vere gastric troubles, globus, and cardiac weakness. The " sinking 
sensation in the epigastrium " is a leading indication. 

Cimicifuga is an analogous remedy when, in addition to this 
symptom of ignatia, it has that peculiar infra-mammary pain which 
is so persistent in some women. 

Cyprepedium, Scutellaria, and passiflora are of great benefit in 
the intense nervousness and insomnia. 

Sumbul, a vegetable musk, is highly esteemed by Dr. Goodell and 
Russian physicians. Give a granule of one-tenth of a grain, to be 
repeated every hour, in hysterical palpitation, cough, and asthma. 
Finally, do not forget to examine for uterine or ovarian troubles, and 



862 THE PRACTICE OF MEDICINE. 

treat them, before you use medicines for the transitory symptoms. 

Hysterical pseudo-disease of the joints is often mistaken for rheu- 
matism or hip disease. These joints have been treated for months 
as a rheumatic affection, baffling the best efforts of the physician, 
when the disease was all the time a pure hysterico-neurosis. Bram- 
well on Diseases of the Joints gives the best and most complete de- 
scription of this strange disease. He reports curing one case of 
hysterical knee-joint disease by giving his opinion that excision of 
the joint was necessary. The patient was placed under ether and 
an incision several inches long was made on each side of the joint* 
only through the skin, which was sewed up. On regaining conscious- 
ness she was told that excision was not found necessary, but that she 
would be well as soon as the cuts were healed, which prediction 
proved true. 

These are the cases, termed chronic rheumatism with paralysis 
or deformity, that have been cured by prayer, by "Christian science," 
the " laying on of hands," and many other irregular methods, hav- 
ing as their basis the power of suggestion or faith. 



NEURASTHENIA (Nervous Exhaustion). 

Definition. — The term neurasthenia is of Greek derivation, and 
literally interpreted means lack of nerve strength. 

The popular idea of neurasthenia is just the opposite. It is sup- 
posed to be synonymous with nervousness, which is not lack of nerve 
strength as a whole, but rather nerve force irregularly distributed, 
or in a state of irritation. Neurasthenia is a low-tension condition. 
Nervousness is a high-tension of the nerve cells. In nervousness 
the nerve cells have not been exhausted, they are in a condition of 
functional irritation. 

I do not intend to imply that we can always draw the line between 
the two conditions, for it is often impossible. 

I make this distinction for humane considerations. The ignorant 
public has been very cruel towards neurasthenics. Not only this, 
but members of the same family, a loving wife or husband, are often 
cruel as the grave. If they knew how cruel they were, they would 
be stricken with inconsolable remorse. In my early practice, before 



DISEASES OF THE NERVOUS SYSTEM. 863 

physicians knew anything about the real nature of this malady, they 
too were cruel. Now there is no excuse for it, either in physicians 
or the people. 

I have known business men, who, while struggling for a compe- 
tence, after years of overwork by day and night, found their mental 
and nervous energy begin to fail. Still they worked on, until night 
after night of sleeplessness, and confusion of mind by day, compelled 
them to relinquish a work that they could not accomplish without 
utter prostration. Such men often retain their appetite, their color, 
and a generally good appearance. 

The family doctor would be called in and would call it "malaria,"' 
or "general debility," and prescribe a routine tonic, and tell the 
patient and wife that " he will be around soon," and advise him to 
keep at work. I need hardly follow the history of such a case, but 
after a time the doctor would fall back on the diagnosis of " nervous- 
ness." The wife would become discouraged, fretful, and unsympa- 
thizing, and in the end cruel with taunts and sneers. 

If we turn the picture, we find the same thing occuring to a woman 
worn out with family cares, rapid childbearing, and, in addition, the 
demands of society, church, and charitable work. The ignorant phy- 
sicians call it hysteria, or nervousness, and the whole crowd of rela- 
tions and acquaintances take up the cry. They say she has whims, 
vapors, or that she is lazy. 

Depend upon it, the neurasthenic a quarter century ago had a 
hard time of it. If poor, the cruelty and indifference was appalling. 
If rich, they could worry along better, but their lot was not enviable, 
for they were sent from one climate to another, from one physician 
to another, and kept in perpetual unrest. Rest, the very thing both 
classes ought to have had, was denied them. The most lamentable 
result was that many neurasthenics of all classes and of both sexes, 
driven in desperation to the use of opiates and stimulants, were lost 
beyond redemption. 

I well remember what a great light broke in upon my mind when 
I read that immortal work of the lamented Dr. George M. Beard on 
"Nervous Exhaustion." With a master-hand he rent the clouds of 
ignorance and stupidity, and showed the medical profession the real 
nature of this disease. It is true that a few physicians had seen 
glimpses of the truth, but they were not bold or acute enough to dis- 



864 THE PRACTICE OF MEDICINE. 

cover its real nature. I advise every physician to read and study Dr. 
Beard's works on " Nervous Exhaustion," " Sexual Neurasthenia," 
and " American Nervousness." In his first essay he uses the general 
term neurasthenia to cover all forms and types of nervous exhaustion ; 
the symptoms coming from the brain and from the spinal cord being 
described together and indiscriminately. In his later works he indi- 
vidualizes and describes the various forms. 

The disease is now divided into several forms. There is Cere- 
hrasthenia, or brain exhaustion; Myelasthenia, or spinal exhaus- 
tion, etc. 

In my work on " Diseases of the Heart," I described Cardiasthe- 
nia, which I believe to be a localized form of neurasthenia. 

I shall not attempt to give the causes or all the symptoms of this 
malady, referring my readers to the works of Dr. Beard ; but I will 
enumerate those most salient and noticeable, and give them without 
his explanations. 

Tenderness of the Scalp> (cerebral irritation). — This is to the 
head what spinal irritation is to the spine. As in spinal irritation, 
the head is not tender all over, but only in spots. This tenderness 
generally occupies the ramifications of the occipital nerves, and is 
often mistaken for cervico-occipital neuralgia. 

Dilated Pupils, or abnormal activity of the pupils, or unequal 
size of the pupils. 

Sick Headache and pain, generally a pressure, heaviness, or burn- 
ing on the vertex. 

Changes in the Expression of the Eyes, at one time dull and 
expressionless, then unusually bright. Congestion of the conjunc- 
tiva is a common symptom. 

Occular Neurasthenia is very common and is the plague of occu- 
iists. I have patients with neurasthenic asthenopia who have had 
their spectacles changed a dozen times a year. No sooner is one 
condition of the muscles corrected than another morbid condition 
takes its place. 

Auditory Illusions, such as ringing, whizzing, roaring, explosions, 
etc., annoy the patient, although the aurist cannot find a single ob- 
jective symptom in the ears. Sometimes the voice changes ; taste 
becomes abnormal, but the most annoying symptom is deficient men- 
tal control, and it is generally allied to mental irritability. 



DISEASES OF THE NERVOUS SYSTEM. 865 

Hopelessness is a common symptom, so is also morbid fear, fear 
of every thing or of only one trivial thing. Fear of being alone I 
have oftener observed than any other. Almost as common is a fear 
of something indefinable, they cannot say what, but it is generally of 
" something dreadful going to happen." 

Nervous Dyspepsia is a most distressing and uncontrollable symp- 
tom. Desire for stimulants and narcotics. Tenderness of the spine. 
(I have described under spinal anaemia the condition called myelas- 
thenia by Beard.) The tendency to Hay Fever is claimed to be a 
condition common in this disease. There is one characteristic of 
neurasthenics, mentioned by Beard, which has been observed by 
thousands since he called attention to it, the " appearance of youth" 
In other words, patients look much younger than they are. This is 
a good diagnostic symptom, for nearly all other diseases cause an 
opposite appearance. Another curious fact is that neurasthenia may 
affect one-half of the body only. 

The chief fault found with Beard's work when it first appeared 
was that he enumerated among the symptoms of neurasthenia those 
of nearly all diseases of the brain and nervous system. This is true, 
and the reason is that this disease, like hysteria, will imitate all forms 
of nervous disease and others not nervous. It will imitate closely 
many of the diseases of the reproductive system, even the structural, 
but when you examine the patient, touch or sight fails to discover 
any objective symptom. 

The accurate diagnosis of neurasthenia requires all the acuteness, 
good judgment, and reasoning powers that an intelligent and well- 
educated physician can bring to his aid. His responsibility is very 
great. His patience and sympathy will be demanded, and should be 
abundant. It must be carefully diagnosed from inflammatory con- 
ditions of the brain and cord ; from tubercular affections of the same 
organs ; from hysteria and malingering, and from what a recent 
writer, Dr. Myrtle, calls "False Neurasthenia." 

Dr. Myrtle writes as follows upon this subject : " We may find 
symptoms in every respect similar to those of true neurasthenia, and 
it will take you all your time and patience, as well as tact, to detect 
the sham from the real. If you hark back a bit, you will find that 
as a child she showed temper ; as she grew, she became fitful, hyster- 
ical, and given to the sulks ; craved for sympathy, and exhibited little 

55 



866 THE PRACTICE OF MEDICINE. 

or no sympathy for others. On questioning her, she describes her 
sufferings in forcible language. She can neither eat or sleep ; has 
not an atom of strength ; suffers from the most dreadful pain, most 
fearful headaches, and frightful spasms ; and should you suggest any 
portion of her body, from her head to her heels, as possibly exempt 
from pain, she often resents the insinuation, and declares that is the 
very part where she suffers most. While she tells you all this in a 
sort of a whine, her features don't show indications of any agony, and, 
if you watch her, you will find that she overacts her part. Utterly 
indifferent to the anxiety of parents and friends, or to the trouble 
and expense she causes, she seemingly finds gratification in watching 
the unwearied efforts of those around her in doing their best to com- 
fort and help her. While putting on an air of the most abject list- 
lessness while you look at or speak to her, if you talk at her you will 
find she has both eyes and ears ; if you assist her in any way she 
makes herself as helpless as she can — a dead weight. These crea- 
tures not only deceive everyone around them, but in time succeed in 
deceiving themselves. Were it not so I cannot understand how they 
continue playing such a sorry game for so long, and with so much 
strain and fixity of attention, to the exclusion of everything else, as 
I have seen them do. If we push our inquiries a little further, we 
generally discover that there is some obliquity of the moral sense ; 
an ungratified whim or disappointed affection at the bottom." 

Treatment. — Dr. Beard remarks : " Each case of neurasthenia is 
a study in itself. No two cases are alike in all details. If two cases 
are treated precisely alike from beginning to end it is probable that 
one of them is treated wrong." This reads like a paragraph out of 
the Organon of Hahnemann. What is true of neurasthenia is true 
of nearly every disease, for neither are the symptomatology nor 
pathology alike in any one disease. 

In neurasthenia, as in all other diseases, the totality of the symp- 
toms must be the one guide to the selection of the medicines used. 
This assertion, however, is subject to one qualification. We must 
not, select a medicine that has no affinity for the nervous system. 

Nearly all the so-called antipsorics in our Materia Medica, by the 
multiplicity of their symptoms will cover all the symptoms of neura- 
sthenia, but this fact does not make them curative remedies for 
neurasthenia. The fact is, that hut few of the antipsorics are really 



DISEASES OF THE NERVOUS SYSTEM. 867 

remedies for neurasthenia. The seat of the multiform disease called 
by the general term neurasthenia is in the brain and spinal cord, and 
a medicine capable of curing it must be one which has a specific 
action on those great nerve centres. 

The aphorisms enunciated by Dr. Beard are as applicable to one 
school as to another. He says : (1) " The treatment should be 
constitutional, with special attention to local manifestations whenever 
they become severe. To devote the whole attention to special or local 
manifestations : as spinal, or cerebral irritation ; cerebral hyperemia ; 
asthenopia; oxaluria, insomnia, or nervous dyspepsia, is unphilo- 
sophical and will never be successful." 

(2) " Dependence should be placed not on any one exclusive 
mode of treatment, but rather on a combination of various methods, 
local and general." 

(3) " The treatment should be occasionally changed, according to 
the needs of the patient." 

"It is not possible," he says, "to set the rudder so that the ship 
may steer straight across the Atlantic ; it must be watched each mo- 
ment, and shifted with the winds and currents. It is equally impos- 
sible, by a single prescription, to steer a neurasthenic sufferer over 
the long voyage to health. Individual idiosyncrasies must be reli- 
giously respected, and when we find that a patient cannot bear one 
remedy or mode of treatment, we can fall back on other remedies." 
(Beard's Nervous Exhaustion, p. 133.) 

He makes one very important suggestion, that at times treatment 
should be entirely withdrawn. We have all heard a patient say, 
" Your medicine had no good effect while I was taking it, but after 
I stopped it I began to improve." This does not imply, as patients 
believe, that this medicine was of no value, rather the contrary. It 
shows that the remedy was the right one. Hahnemann observed the 
same results, and therefore he often advises us not to interfere with 
this improvement, and not to repeat the medicine until the improve- 
ment ceases. 

When 1 have selected the radical or constitutional remedy, I or- 
der it taken continuously for a week or two ; if, during that time, 
the patient observes decided improvement, it is taken at longer in- 
tervals, or in smaller doses. 

If no improvement sets in within a reasonable time, stop the 



THE PRACTICE OF MEDICINE. 

medicine altogether. Then improvement will be observed, and this 
improvement should not be interfered with. 

The following are the constitutional remedies which may be indi- 
cated in the treatment of neurasthenia : 

Absinthum, aconite, agaricus, alstonia, anacardium, argentum, 
arsenicum, asafoetida, aurum, baryta, cannabis indica, coccrdus, cup- 
rum, cimicifuga, convallaria, digitalis, ergot, lycopodium, ignatia, 
nux vomica, phosphorus, phosphoric acid, picric acid, picidia, Pulsa- 
tilla, sabadilla, sepia, silicea, stannum, strychnine, tellurium, viscum, 
and zinc. We do not yet appreciate the value of compound reme- 
dies. It is a mistake to suppose that they must be proven before 
we can use them. The symptoms of both remedies indicate the 
compound of the two. Thus the arseniate of gold is indicated when 
the patient has many of the symptoms of both, and neither drug has 
them all. It may be asked, why not follow Hahnemann's advice, 
and give one until the symptoms indicating it disappear, and then 
give the other if its symptoms remain. I reply, that it is a waste of 
what might be valuable time. Then why not alternate them ? I 
again reply, that time might be wasted, for we do not get the united 
force of both at the same time. A simple illustration will explain 
my meaning. If two men are set at work to lift a heavy weighty 
should they alternate in their efforts ? Both would not accomplish 
more than one. But if they lift together, they exert the power of 
two. As a fact, I have often observed more and prompter curative 
or physiological force from two remedies given in combination than 
when given separately. 

The following are some of the compound medicines likely to be 
useful : Arseniate of gold, arsenite of quinine, and arsenite of strych- 
nine ; also the arseniates of copper and iron, and the picrate and 
phosphide of zinc, hypophosphite of lime, bromide of gold, and bro- 
mide of nickel. 

I have been quite successful with the arsenite of strychnine, the 
bromide of gold, and the phosphide and picrate of zinc. They 
cover a vast array of symptoms, and reach the radical cause of neu- 
rasthenia. The palliatives oftenest of use for the various local man- 
ifestations are so many that they cannot all be enumerated. The 
most important are aconite, belladonna, coffea, coca, epiphegus, 



DISEASES OF THE NERVOUS SYSTEM. 869 

bromides of sodium and strontium, asafcetida, Scutellaria, valerian, 
sumbul, glonoine, kola, phenacetin, piper meth., pauliana, etc.* 

Medical treatment alone will not accomplish much, unless com- 
bined with hygiene. We must correct abnormal habits ; prohibit or 
advise mental and physical exercise or labor ; advise travel or isola- 
tion, as seems indicated for the patient. The diet is important. 
Not enough fatty food is taken by neurasthenics who generally are 
averse to it, but it can be so disguised as to be palatable. It is the 
greasy appearance and taste which they dislike. 

Sugar and starch are to be avoided as much as possible. I am 
inclined to the opinion, that, except in rare cases, red meats of all 
kinds are not suitable. Beef, I am sure, does not agree. A vege- 
table diet combined with plenty of bacon, butter, salad oil, cocoa, 
nuts, etc., the use of the albuminous and gluten of cereals, and milk 
or matzoon, is the ideal diet for nervous prostration. 

Rest is one of the most important means of recovery in the ma- 
jority of cases ; rest for the portion of the nervous system principally 
affected. Those faculties of the brain that have been strained and 
have become exhausted, should be made to rest. This does not mean 
that the whole brain should be compelled to rest. The brain cells, 
exhausted by the cares of financial excitement, should rest ; but 
others, like those which preside over music, the sports of hunting and 
fishing, or historical study, can be exercised. 

When the whole cerebrum has been exhausted by multifarious 
mental labors, the patient should be advised to resort to physical 
labor — gradually, at first, until the long unused muscles are accus- 
tomed to exercise. In rare cases it is absolutely necessary, in women 
especially, to isolate them entirely from friends and relations. Dr. 
Weir Mitchell has gained a world-wide reputation for his success by 
this method. He claims that it is impossible to cure a neurasthenic, 
especially if hysterical, unless she be isolated. It is not necessary 
that she should be shut up with a stupid and disagreeable nurse, for 
many of the trained nurses of to-day are intelligent thoughtful women, 
and are as patient and sympathetic as is necessary. Friends and 
relatives are either too sympathetic or too indifferent and irritating. 

* For the indications of many of the above remedies, refer to the articles on 
Cerebral and Spinal Ansemia and Hyperemia. 



870 THE PRACTICE OF MEDICINE. 

No correspondence except on business matters should be allowed. 
Letters are often an exasperating source of annoyance. The patient 
can be read to, and interested in things that do not excite or irritate 
her. In the pleasant, quiet suburbs of every city there should be a 
Hotel or Retreat for nervous or nerveless patients. Then, when a 
man or woman felt an imperative need of quiet and nerve repose, 
they could go there for a few days or weeks. It would be much bet- 
ter for them than to resort to drugs. I need not advise the judicious 
use of electricity and massage, because these powerful agents are so 
commonly adopted by all schools. Nor need I mention the value of 
" suggestion," by which Charcot cured so many recent cases of all 
kinds of nervous disorder. In skilled and conscientious hands hyp- 
notism may be of great value. 

Travel as a remedy for neurasthenia has been advised in cases 
where it is decidedly contra - indicated. In spinal neurasthenia 
patients are very liable to be made much worse by travel ; the fatigue, 
discomfort, and sight-seeing injure them. They are far better off 
at home. The spinal cord wants rest. Nor should horseback rid- 
ing be advised, it aggravates. In the beginning of brain exhaustion, 
travel, by diverting the mind and bringing new faculties into use, 
may be of benefit. 

Climate has a large influence over neurasthenia, both good and 
bad. A change of climate should be advised with caution. My 
observations have convinced me that neurasthenia is a disease of the 
temperate zones. The further south we go, the less we shall find of 
it. Americans in New Orleans suffer less from it than in New York, 
Chicago, or Boston. It is less often found in low, humid regions 
than at high altitudes. For this reason never send neurasthenics to 
Colorado, California, or any region of high altitude — over 1,000 
feet above the level of the sea. The best place in the United 
States for such patients is the middle third division of Florida, i. e., 
from a line along 29° to 26° of latitude, or that belt lying between 
Enterprise, on the north, to Charlotte Harbor, on the south, in which 
lie such places as Winter Park, Enterprise, Orlando, Tampa, Rock 
Ledge, Lake Worth, and especially Pine Island with its quiet hotel, 
its facilities for fishing, boating, and its delicious climate from Decem- 
ber 1st to April 1st. Ft. Myers, on the main land, also Naples, 
the most southern location attainable this side of Key West, are 



DISEASES OF THE NERVOUS SYSTEM. 871 

excellent spots. Next to these are the Barbadoes, Cuba, Nassau, 
and Jamica. 

Never advise a patient with neurasthenia to go to Europe with- 
out a definite purpose. If the case is severe enough, and " money 
no object," send him to Dr. Charcot* of Paris, who will give him 
some kind of a shock, in the way of unique treatment, or send him 
to some quiet water-cure in Germany. There are cases of cerebra- 
sthena that are cured only by a long sea-voyage on a sailing vessel. 
I recall two cases where this condition resisted all treatment, but a 
voyage " round the Horn " to California cured them. One, an 
Englishman, informed me he had made three such voyages at inter- 
vals of five years, each voyage occupying about six months. On his 
return to London each time he was perfectly restored. 

A winter residence in the pineries of Michigan or Wisconsin has 
cured many cases. I sent a clergyman to the Island of Mackinaw 
for the winter. He returned cured. Not only a change of climate, 
of location, but a change of business is sometimes necessary. 

(As I write this I find in a recent journal an account of the treat- 
ment of neurasthenia by the injection of a glycerole extract of sheep's 
brains. The results are said to be better than from any other treat- 
ment. This is an old idea in medicine, renewed by Brown-Sequard. 
The Scandinavian hunter eats the lungs of wolves for dyspnoea ; the 
Romans ate the testicles of animals noted for their virility, to restore 
failing virility. There seems to be some basis of truth in that ancient 
belief. Dr. Hammond uses successfully injections of Cerebrin. It 
can be given on the tongue, in the lx or 2x dilution.) 

INSOMNIA. 

Definition. — Insomnia does not mean sleeplessness from all 
causes. When the inability to sleep arises from pain, or definite 
physical discomfort, it cannot properly be called insomnia. I con- 
side true insomnia to be an abnormal state of the brain and nervous 
system, without pain, which prevents normal sleep. 

" Normal sleep may be defined in general terms as that state of the 
central nervous system in which the higher centres are to a great 
extent in a state of physiological quiescence, with all the consequences 
thereby implied. In its most profound form, and probably in its 

* Since the above was written, Dr. Charcot has died; an irreparable loss to the 
world at large. 



872 THE PRACTICE OF MEDICINE. 

most perfect manifestation, there is a total cessation of the strictly 
psychical functions. The automatic and reflex centres, on the con- 
trary, are active, so that the functions dependent thereon, such as 
respiration, circulation, digestion, secretion, etc., are regularly car- 
ried on. (Dr. J. L. Corning, "Physiology and Pathology of Sleep.") 

The experiments of Hammond, Fleming, Durham, and Corning 
prove beyond question that the degree of sanguineous irrigation of 
the encephalon is in direct proportion to the amount of functional 
activity of that organ. When the activity of the brain is greatest 
the hyperemia of the meninges obtains a maximum degree of inten- 
sity ; whereas, during the functional quiescence of sleep, the amount 
of blood circulating in the vessels of the pia mater is at a minimum. 
Corning divides insomnia into idiopathic and symtomatic. The 
former is a sleeplessness, the predisposing causes of which cannot be 
traced to any particular source extraneous to the brain itself. The 
latter to that form of the disorder which may be observed in the 
course of many acute and chronic diseases. This definition is too 
broad for consideration in this article, for it would include fevers 
and pain. 

The causes of sleeplessness aside from pain or discomfort are too 
many to enumerate. An exaggeration of any mental emotion may 
cause it ; sorrow, jealousy, fear, disappointed ambition, suspicion, 
sudden pecuniary loss, excessive joy, or pleasant anticipation, all may 
cause sleeplessness. 

Besides these there are causes which defy the acumen of the pa- 
tient and physician to discover. Many men and women, who seem 
in perfect physical and mental health, with not a known cause for 
mental anxiety, will complain of continued inability to sleep the 
whole or part of a night. They may go to sleep when they go to 
bed, and sleep till two o'clock a. m., and then lie awake until day ; 
or they may toss about till after midnight, and then fall asleep, wak- 
ing at the usual hour, unrefreshed. This form of insomnia should 
be very carefully investigated, for it may mean that some insidious 
brain trouble is impending. 

When insomnia depends on mental causes it will, unless checked, 
result in permanent impairment of the brain and some form of in- 
sanity. When sleep does occur in such patients, it is not normal. 
It is attended by dreams of a vivid, disagreeable, or painful charac- 



DISEASES OF THE NERVOUS SYSTEM. 873 

ter. Patients have often said to me, " Such sleep as I get is worse 
than none." All the cares, anxieties, and grief of the waking hours 
are carried into the domain of abnormal sleep. It must not be for- 
gotten that a patient may experience all the mental emotions men- 
tioned as causes of insomnia, without having any real cause for such 
emotions. Fear, joy, grief, apprehension, and jealousy may be illu- 
sory manifestations of a disordered mind and brain ; but these hal- 
lucinations are just as much causes of insomnia as if the emotions 
were based on actual occurrences. 

Sleepless nights often occur while one is in seeming health, just 
before the onset of a febrile attack, particularly before a malarial 
paroxysm. Certain conditions of the atmosphere cause sleeplessness 
in impressible persons, but we have been so far unable to classify 
and explain its method of action. 

Physical weariness without actual pain causes insomnia. The 
expression " too tired to sleep " is a common one. Some of the toxic 
constituents of the urine if retained in the blood cause an uncontroll- 
able sleeplessness, which will persist until the kidneys excrete them. 
In such cases our remedies should be directed to those organs instead 
of to the brain. Remedies which increase the excretion of urea will 
cure the insomnia. If morphine or any preparation of opium is given 
for such a condition, serious results may follow, for opium prevents 
the excretion of urea. Retention in the blood of some of the toxic 
bile constituents causes obstinate insomnia, and requires hepatic rem- 
edies. 

Treatment. — The whole medicinal treatment of insomnia by the 
" regular " school is based on pathological data. They contend that 
as the brain during sleep is anaemic, and during insomnia hypergemic, 
therefore drugs must be given to cause cerebral anaemia. The theory 
is plausible, but the fact is that antipathic drugs never cure a chronic 
insomnia. They palliate, and as palliatives are useful in acute cases, 
I admit that in insomnia due to transient causes, they may, by causing 
sleep, prevent the habit from gaining a foothold, and thus ward off 
injurious results to the brain. 

Homeopathists are equally in error if they suppose that in all 
cases they can cure insomnia due to mental and nervous causes by 
giving remedies which cause sleeplessness by their primary action. 

There are cases where it is imperatively necessary to the welfare 



874 THE PRACTICE OF MEDICINE. 

of the patient that we should cause artificial drug-sleep — a sleep 
produced by a physiological effect on the brain or its blood-vessels. 
It is often as important as to put an injured limb in splints. 

Hypnotics, when properly chosen, restrain the blood from flowing 
to the brain, and inhibit temporarily the morbid activity of the cere- 
bral cells. While this sedative action in the cells exists, they are 
having a physiological rest and are more likely to recover their nor- 
mal tone. I do not wish to be understood as underrating homeopathic 
remedies. I know their value too well to discard them, and I have 
seen their beneficent action in many cases where antipathic drugs had 
to be abandoned as injurious and useless. 

The drugs which are homeopathic to sleeplessness from cerebral 
hyper semia include all the cerebral stimulants. The most important 
are opium, aurum, belladonna, agaricus, hyoscyamus, stramonium, 
lachnanthes, solanum, coca, cannabis indica, coffea, tea, ilex cassine, 
ilex paraguayensis, etc. The primary effect of all these when taken in 
small quantities is to increase the amount of blood-supply of the brain, 
causing wakefulness. It is only when large doses are given that sleep 
is induced. In fact, there are some persons who become delirious 
from doses that would cause sleep in others. Several of the above- 
mentioned drugs cause a sleeplessness attended by sleepiness. Those 
under their influence feel sleepy but cannot fall asleep. Opium, 
belladonna, agaricus, and hyoscyamus are notable examples. Others, 
like coffee, cannabis indica, tea, coca, cypripedium, and Scutellaria, 
cause complete wakefulness without the slightest sleepiness, but a 
condition of the mind in which the thoughts are unnaturally clear, 
active, and untiring. " They cannot go to sleep on account of the 
flow and multiplicity of thoughts." 

These same drugs, as well as chamomilla, cactus, ignatia, Pulsa- 
tilla, and nux vomica cause such a hyperaesthetic condition of the 
senses of hearing, touch, and sight, that all sounds, or contact, or 
light, keep the person awake. This is a common form of insomnia. 
The victims long for a place " where nothing happens "; " a place 
in the country ; on an island, miles away from anything that can 
make a noise, except the gentle wind among the trees, or the murmur 
of waters." 

If any of the medicines of which I have given the chief charac- 
teristics are indicated they must be prescribed in minute doses from 



DISEASES OF THE NERVOUS SYSTEM. 875 

the 3d to the 30th. Indeed, if there is any place for the high dilu- 
tions it is in this malady. Now it is my belief, which eminent phy- 
siologists have demonstrated, that all those drugs which primarily 
cause active hyperemia of the brain cause by their secondary effects 
passive hyperemia, and even anaemia, both of which conditions cause 
insomnia. When passive congestion is present larger doses will be 
required, i. e., large enough to cause slight physiological action. 
Medicines have more effect over sleeplessness from imaginary than 
real sorrows. The former are due to some derangement of the cere- 
bral cells or the circulation, or the blood which supplies them. I 
know from positive experience that hyoscyamus will cure sleepless- 
ness from imaginary jealousy, sense of being wronged, or anger and 
vindictiveness without real cause, or when the patient is sleepy and 
dull during the day and becomes very irritable and sleepless at night. 
This sleeplessness (in the insane) is attended with violent agitation, 
choreic movements, jactitation, twitching, and delirium of a destruc- 
tive character. It is in just this kind of insomnia that the physicians 
of insane asylums report to have found hyoscyamine very useful. 
(Duboisine, in similar doses, is said to act like hyoscine.) From 
hyoscine and hyoscyamine l-500th and l-1000th of a grain, I have 
seen almost magical results. 

Aurum is a splendid remedy for insomnia when one is kept awake 
by joyous thoughts, more joyous than occasion warrants. There is, 
at the same time, an ebullition of the blood ; it seems to seethe and 
beat all over the body. This is the primary effect. The secondary 
effect of gold is to cause a torpor, coldness, and inaction of the whole 
body. The pulse is weak and slow, the mind depressed, melancholy, 
with thoughts of suicide, especially at night and when alone. For 
this condition the 2x of aurum acts curatively, while for the former 
state the 6x acts equally well. I have stated that a true insomnia 
is not caused by pain, but there is a condition of erethism or hyper- 
esthesia of the nerves of sensation, just as there is of the nerves of 
motion. In the former, a sensation which in health would not be 
painful — only annoying — is exaggerated into the semblance of a real 
pain, and causes the patient so much suffering as to keep him awake. 
The remedies for this condition are cannabis indica 3x, coffea 6x, 
chamomilla 2x, valerian lx, and valerianate of strychnine 6th, igna- 
tia 6x, cactus 3x, Scutellaria lx, and monobromide of camphor lx to 



876 THE PRACTICE OF MEDICINE. 

3x. It is in such cases that Charcot's method of " suggestion " is 
applicable and of real value. The patient may be brought slightly 
under hypnotic influence, and then told quietly but firmly that she 
will fall asleep at a certain hour. This method generally succeeds. 
Another plan is to give a blank powder, or some discs saturated with 
some simple bitter substance, as gentian or columbo, and to insist 
that one or two taken when she goes to bed will cause sleep in about 
an hour. If I have the confidence of my patient, I have succeeded 
by this method when medicines failed. It is worth trying, and per- 
fectly justifiable. 

We turn now to a consideration of those medicines whose physio- 
logical effect is to cause sleep. Not all of them cause a normal sleep, 
in fact the medicines capable of this effect are very few, because 
normal sleep is not a negative, but an active, healthy physiological 
state. 

The first class comprises those which cause sleep but have not 
the power to alleviate pain of a severe and positive nature. Chloral 
hydrate, the bromides, chloralamide, paraldehide, urethan, sulfonal, 
passiflora, somnal, and many others, have been largely used during 
the last few years. In recent cases of insomnia from grief and other 
powerful mental emotions, when the homeopathic remedy is not suf- 
ficient, I still keep my preference for chloral hydrate. A dose of 
ten, fifteen or twenty grains acts pleasanter, quicker, and causes a 
more natural sleep than any other drug. I know that some persons 
have an intolerance of it, and that it is not safe when there is a weak 
heart. In the latter case it should be combined with bromide of 
potassium in equal parts and given largely diluted- I have used 
chloralamide, paraldehyde, and urethan, but they are not better than 
chloral, although it is stated that they are well borne when chloral 
is not. 

Sulfonal was very popular until it was discovered that toxic effects 
followed the medicinal dose in some persons. At first it was lauded 
as an absolutely safe hypnotic, but the same was asserted of every 
new drug when it first appeared. I do not consider it in any sense 
dangerous in doses of ten or fifteen grains, but its use should not be 
continued more than a few nights. It should be taken in the form of 
powder, or effervescing salt in hot water, and about an hour after the 
6 o'clock meal, and the patient should go to bed within an hour. The 



DISEASES OF THE NERVOUS SYSTEM. 877 

dose can be decreased instead of increased. In this respect it resem- 
bles chloral. Trional often acts better than sulfonal. 

The bromides are so well known that I need not discuss them, but 
will state my preference for the bromide of sodium, as it is the most 
harmless of all. I never observed the favorable results Hammond 
claims from the bromide of calcium. Bromide of lithia acts quicker 
than any other, and is more useful in the sleeplessness which pre- 
cedes apoplexy or cerebral rheumatism. The monobromide of cam- 
phor is a precious medicine for women and children, and neuras- 
thenic men. It should be given in the lower triturations. Ten grains 
of the lx is the largest dose necessary, and in children the 3x acts 
admirably. 

Passiflora is a drug the position of which in materia medica has 
not yet been definitely settled. It is somewhere between gelsemium 
and chloral. It will cause sleep when pain is the cause of insomnia, 
or when it is caused by mental irritation, or when no cause can be 
assigned or felt. The dose is from ten to thirty drops every hour. 

Pulsatilla lx, aconite 3x, and arsenicum 6x will cause sleep when 
anxiety, restlessness, and fear of something indefinable is present. 
For that state, best defined as " figgitiness," pulsatilla nuttaliana is 
superior to the foreign plant. 

Phenacetin, besides being one of the most trustworthy analgesic 
(anodyne) drugs yet discovered, is one of the best and safest of all 
hypnotics. In medicinal doses (five to ten grains) it causes no 
unpleasant or toxic symptoms. It seems to be a sedative to the gen- 
eral nervous system, and is equally good for sleeplessness from severe 
pain, as it is when no pain or discomfort are present. It is one of 
the best hypnotics for children (lx or 2x triturate) when the sleep- 
lessness is from teething or from cerebral irritation. It acts well 
after coffea, bromide of camphor, and belladonna have failed. 

Antipyrin, antifebrin, exalgine, and others of the same nature 
may under certain circumstances act equally favorable, but I rarely 
use them. In the sleeplessness of hysteria, bromide of camphor, 
asafoetida, castorium, valerian, and platina are useful. 

Picidia erythena (Jamaica dogwood) has been found useful in 
insomnia. Its physiological action on the brain resembles that of 
chloral and hyoscyamus, having some of the effects of each. It has 
relieved insomnia from alcoholic excess (delirium tremens) and the 



878 THE PRACTICE OF MEDICINE. 

wakefulness of insanity. It is anodyne as well as hypnotic, and has 
relieved the pain of facial neuralgia, hemicrania, ovarialgia, and sci- 
atica when they prevented sleep. When given for pain the dose is 
ten to twenty drops every two or three hours, and for sleeplessness 
alone twenty to thirty drops. I found it excellent in the insomnia 
from cardiac excitement, when the heart-heats were hard and rapid. 
In moderate doses it quiets cardiac irritation, and slows the heart's 
action. 

The absence of an accustomed noise will often cause insomnia. 
People in health who go from the city into the quiet country cannot 
sleep for several nights, " because it is so still." The accustomed 
noise of a mill, the roar of the ocean, the dashing of waves on a beach 
becomes so much the part of the life of a person that their absence 
causes insomnia. I have known several persons who could not sleep 
for a week, because the clock which had been in the room for years 
ceased its monotonous ticking. Others could not sleep if they did 
not hear a watch ticking under their pillow. The brain-cells become 
so habituated to such noises that they miss them. 

We become habituated to going to bed at certain hours. If we 
change the hour it is apt to disturb our sleep. If we are accustomed 
to eat heartily in the evening, we cannot sleep if we eat less, and the 
contrary also obtains. Dr. Eggleston says that most students and 
women who are troubled with insomnia are dyspeptic, and he has 
found it easy to treat successfully such cases without medicine. They 
are instructed to eat before going to bed, having put aside work 
entirely for at least an hour. If they are not hungry, they should 
be simply instructed to eat ; and if they are hungry they should eat 
whatever they want. A glass of milk and a biscuit is sometimes all 
that can be taken at first, or a mashed potato buttered. In a short 
time the night appetite will grow, and the appetite will then need 
no particular direction. If possible, the night meal should be taken 
in a room other than the sleeping apartments, and for men in the 
city it will be found advantageous to go out to a restaurant. The 
idea of going out for something to eat and having to wait a short 
time for it will excite the appetite. Before eating, however, a bath 
should be taken ; I much prefer cold or cool baths, which should be 
given with a sponge or stiff brush, and the body thoroughly rubbed 
off with a coarse towel afterwards. The bath need not be more than 



DISEASES OF THE NERVOUS SYSTEM. 879 

five minutes in duration. After the bath and rubbing, or after eat- 
ing, a moderate amount of exercise should be taken. For this, a 
few minutes with Indian clubs or dumb-bells is sufficient. Further 
than this, the patient should go to bed at the same hour every night, 
and arise at the same hour every morning. There is a popular super- 
stition that grown people should not eat immediately before going to 
sleep ; that it will give them indigestion or night-mare, or both. Dr. 
Eggleston cannot see why adults should be very different in this 
respect from babies. We know that young children awake at night, 
and must have something to eat before they will sleep quietly, and 
that some children actually fall asleep with a nursing-bottle leak- 
ing into the mouth. It may be true that digestion is carried on 
slowly during sleep, and that the digestive function is less active, 
but here one need not be in a hurry for the completion of the oper- 
ation. The average person should be in bed seven or eight hours, 
which is time for the digestion of almost anything edible. In our 
American life, he thinks, the digestion carried on through sleep prob- 
ably has the better chance for thoroughness. 

I have arrested insomnia in many instances by advising a bowl 
of good bread and milk just before going to bed. These persons had 
been under the care of eminent neurologists who had advised a light 
supper. An empty stomach is a very frequent cause of sleeplessness. 

In an article on the treatment of sleeplessness Dr. Eccles (" The 
Practitioner ") says that in attempting to overcome the partial func- 
tional activity of the brain which appears to account for the dream- 
laden unrefreshing form of sleep, he has employed wet packing, 
abdominal compresses, cold bathing, elevation of the head by means 
of extra pillows, and application of warmth to the extremities by 
means of hot bottles and bags, with very variable and, generally 
speaking, little success ; but a hot bath, taken immediately before 
the time which one wishes the patient to settle quietly for the night, 
has proved most valuable in producing a dreamless sleep, although 
not usually of longer duration than four hours without intermission, 
and sometimes followed by a period of great wakefulness, relieved 
only by a short morning doze ; still, even where this somewhat 
uncomfortable vigil supervenes, the patient always feels more re- 
freshed and happier the next day than after a long night of uneasy 
dreamy sleep. To effect the permanent restoration of refreshing 



880 THE PRACTICE OF MEDICINE. 

sleep a method of treatment is needed which must break the chain 
of vicious circumstances under whose thraldom the patient has lost 
the power to sleep. The brain in these cases is often found to be 
over-worked, and must be allowed to lie fallow as far as possible ; 
the stomach, which has generally suffered with the other organs of 
digestion from extraordinary maltreatment, must be coaxed back 
again to a regular performance of its duties ; while the muscular 
system, which has become wasted and inert from long disuse, must 
be called upon to fulfil its digestive and excrementitious functions, 
so long left in abeyance. Under the combined influence of the 
recumbent position in a quiet room, away from the cares of domes- 
tic, social, or business life, carefully modified diet, and massage 
applied as a therapeutical agent, not without regard to the mode, 
duration, and extent of its administration, the method of treatment 
referred to may be carried out with the happiest results in the 
majority of cases. 

A change from the accustomed bed or sleeping-room, will often 
break up the insomnia for a time ; even a change of the position of 
the bed. There is probably no truth in the belief that some persons 
sleep better when lying with the head towards the north magnetic 
pole. 

Wakefulness is often caused by a light in the room. A sleeping- 
room should be as absolutely dark as it is possible to make it. Espe- 
cially in case of infants and children. 

If a patient with insomnia sleeps with anyone in the same bed, 
advise sleeping alone, shut off from any other room. Some women 
and children cannot sleep if they lie alone. We are obliged to inquire 
into all these conditions if we would be successful in relieving this 
plague of modern life. 

SUNSTROKE. 

(Heat Stroke, Insolation, Coup de Soleil.) 
Definition. — A condition produced by exposure to excessive heat. 
There are now two forms recognized : heat-exhaustion, and heat- 
stroke. 

Heat-exhaustion is caused by prolonged exposure to high tem- 
perature, particularly when combined with severe physical exertion, 
although it may affect persons who remain long in an over-heated 



DISEASES OF THE NERVOUS SYSTEM. 881 

and poorly ventilated room, without exertion. The symptoms are 
extreme prostration, collapse, restlessness, cool surface of the body, 
pulse small and rapid, and subnormal temperature, as low as 95° or 
96°. Exposure to the rays of the sun is not necessary. It may fol- 
low exposure to artificial heat, as in iron mills, or the engine rooms 
in steamships. 

Heat-stroke is chiefly caused by the direct rays of the sun upon 
persons who are engaged in physical labor, especially in cities. Sol- 
diers loaded down with heavy clothing and accoutrements are often 
victims. If the exposed persons have been drinking beer or whisky 
they are more liable to an attack. It is natural to suppose that in 
the tropics sunstroke is more common than in the temperate lati- 
tudes. This is not always the case. We do not yet know why cer- 
tain places in the tropics where the heat is intense have less cases of 
sunstroke than others. It is probable that in low valleys shut in 
by mountain or forests the malady is more common. 

New Orleans and Charleston have many cases, while St. Augus- 
tine and Tampa hardly any ; in fact Florida is singularly free from 
this accident. 

Pathology. — Rigor mortis occurs early, and putrefaction appears 
with great rapidity. The venous engorgement is extreme, particu- 
larly in the cerebrum. The left ventricle is contracted and the right 
chamber dilated. The blood is usually fluid, and the lungs are 
intensely injected. According to Dr. H. C. Wood, whose mono- 
graph on this disease is the best written, " Heat exhaustion with 
lowered temperature represents a sudden vaso-motor palsy, i. e., a 
condition in which the existing effect of the heat paralyzes the vaso- 
motor centre in the medulla." Sunstroke with high temperature, he 
says, paralyzes that centre in the medulla which regulates the dis- 
position of bodily heat. In this form more heat is produced and less 
given off than normally. 

In sunstroke the patient may be struck down and die within an 
hour, with symptoms of heart failure, dyspnoea, and coma. This 
state of things may occur from excessive heat in a close room, if the 
man has been drinking liquor. 

During one hot day in June, I was called to see a man who was 
attacked while working in the close, foetid air of a basement, below 
some horse stables. He was stricken down at 10 a. m, and died at 



882 THE PRACTICE OF MEDICINE. 

3 P. M., with all the symptoms of sunstroke, high temperature, heart 
failure, and coma. 

The usual symptoms are vertigo, pain in the head, oppression, 
vomiting, and colored flames before the eyes. Involuntary diar- 
rhoea and micturition are common. Insensibility, soon deepening 
into coma, follows. The temperature ranges from 107° to 112°. 
During the coma the action of the heart becomes very feeble, the 
breathing hurried, shallow, of the Cheyne-Stokes type. A fatal ter- 
mination may occur within twelve or thirty-six hours. 

Treatment. — In heat-stroke, with sub-normal temperature, feeble 
heart, impulse quick, weak, and small, with cool skin and impending 
collapse, the indications are to stimulate the heart and the vaso- 
motor centre in the medulla. No medicine does this so quickly and 
well as glonoine lc, one or two drops on the tongue, or by hypo- 
dermic injection, every fifteen minutes until reaction sets in. The 
use of ice-cold water and ice in heat-strokes is criminal malprac- 
tice, yet I have seen it done in Chicago by the men sent out in the 
ambulances. 

As soon as the pulse becomes stronger, and the heart's action 
normal, give bromide of camphor lx, alone or alternated with coccu- 
lus, which are excellent remedies for sub-normal temperatures. 

In sunstroke, with its cerebral congestion, headache, delirium, 
high temperature, and tendency to coma, gelsemium is the chief 
remedy. Given in doses of five drops every half-hour, or hour, it 
sometimes relieves the worst symptoms. In typical cases I should 
not hesitate to give the same dose of veratrum viride, until the pun- 
gent heat of the skin, rapid, hard, bounding pulse, and very high 
temperature was reduced. Veratrum will have this effect in fevers ; 
why not in this malady, which is essentially an acute fever ? 

There is a condition in sunstroke which calls for nitroglycerine 
or amyl nitrite : namely — when, notwithstanding the failing heart, 
which appears after the stage of excitement, the temperature remains 
high. Here small doses are required, one or two drops of the l-500th 
solution. A study of the provings of amyl and glonoine shows that 
they can reduce high temperatures with a weak heart, and that their 
effects in many respects are similar to cases of sunstroke. In heat- 
exhaustion stimulating doses are needed. In sunstroke during the 



DISEASES OF THE NERVOUS SYSTEM. 883 

stage of depression, stimulation is also needed, but to a less degree. 
The use of ice, ice-packs, and ice-water baths, now so popular in hos- 
pitals, is of doubtful value, unless in cases of extreme high tempera- 
ture, in very robust men. I am sure it is a dangerous method in 
many cases. The plan pursued in the army is much better and 
more successful. The soldier is stripped and laid in the shade, and 
water from a spring, well, or river poured over him ; or he is placed 
in the water of a stream or spring. Now the water so used is rarely 
below 60° and generally 70°. This is as effectual in reducing a tem- 
perature of 110° as ice, and although it may take a little longer, is 
much safer. 

Phenacetin is the only one of all the antipyretics that is safe. It is 
of real value, as its effects in several cases which I saw early in the 
attack proved to me. It relieved the pain in the head, the high tem- 
perature, and congestion ; two grains were given every half hour. I 
believe it warded off a dangerous termination in each case. 

I cannot recommend the use of quinine, as I believe it is an uncer- 
tain and dangerous drug in sunstroke. It was once recommended 
highly, and used hypodermatically — ten to twenty grains. Among 
the sequelce of sunstroke is great sensitiveness to heat, even temper- 
atures of 75° and 80°, which were not unpleasant before the attack. 
At 80° one of my patients became uneasy, had a feeling of fullness 
or lightness in the head, vertigo, and confusion. I sent him to the 
north shore of Lake Superior, where he improved, but suffered a good 
deal occasionally. For five years he was unpleasantly affected by heat 
and the direct rays of the sun, when I lost sight of him. Osier relates 
the case of a man whom he sent to Alaska to escape the heat, and 
that he was obliged while there to spend most of his time in a cellar. 
There are a great many very mild cases of heat-stroke, unrecognized 
at the time, which leave a sensitiveness to heat, unexplainable until 
the history of the case is traced back. I recall one case, a young 
woman in perfect health, who, after spending some hours in the Mam- 
moth Cave of Kentucky, rode in the hot sun several miles to the rail- 
road station. She was attacked with fever and delirium lasting several 
days, and had suffered for several years from what H. C. Wood des- 
ignates as a kind of chronic meningitis. It is now six years since 
the attack, yet she cannot bear the direct rays of the sun even when 



884 THE PRACTICE OF MEDICINE. 

the mercury stands at 70° in the shade. The medicines which ben- 
efited this patient most were aurum 6x, mono-bromide of camphor 
2x, and glonoine 3c. 

In cases marked by swimming in the head, an uncertain gait, dif- 
ficulty in concentrating the mind, and depression of spirits, phos- 
phide of zinc 3x has been of great service. 

Mono-bromide of camphor 3x, digitalis 30c, opium 30c, and aco- 
nite 3x are remedies of special value in the chronic cases. 



DISEASES OF THE BRAIN AND NERVES. 

It would be presumptuous for me to attempt to give the thera- 
peutics of all the diseases of the brain and nervous system. 

I shall treat only of those of which I have had some experience ; 
or concerning which some new and noteworthy methods of treat- 
ment have lately been discovered. 



IRRITATION OF THE BRAIN. 

Definition, — Cerebral hyperesthesia, with an exalted condition 
of its mental or sensory-motor functions. It may arise from simple 
mental excitement, overwork on business matters, excessive study, 
reading exciting books, or religious excitement. 

In children it is caused during teething by the pressure of the 
teeth upon the tough gums, irritation of the stomach from improper 
food, worms, and irritating substances in the intestines. In adults 
it may arise from retention in the blood of the toxic constituents of 
the bile and urine, or the absorption of the ptomaines from imper- 
fectly digested food and retained excretions. 

In women it often arises from ovarian and uterine irritation. In 
both sexes from neuroses of the sexual organs. 

In children one of the commonest causes of cerebral irritation is 
the use of red meats. No child under five years of age, unless liv- 
ing a very active out-door life, should be permitted beef or beef soups, 
except in the morning. Men and women who are very plethoric 
should not eat beef. I have known beef-eating children to become 
so irritable that they could not be managed during the day, and 



DISEASES OF THE NERVOUS SYSTEM. 885 

their sleep was uneasy, troubled by screams, frightful dreams, or 
convulsive startings or complete insomnia. 

No medicine benefited them, but when beef was taken away from 
their diet they had quiet days and restful nights. The effect of 
feeding beef to animals is well known. It will make the mildest 
become vicious, irritable, and ungovernable. I have treated several 
plethoric butchers, who were accustomed several times a day to eat 
raw beef, and also had beef at their meals. They complained of 
being so irritable that the slightest word or complaint, or anything 
occurring to annoy them, threw them into a rage. They felt vicious, 
pugnacious, sleepless, vertiginous, and had hot flashes and flames 
before their eyes. A diet of fish, chicken, and vegetables caused all 
these symptoms to disappear in a few weeks. 

I observed in such persons that the pulse was hard, full, and 
eighty or ninety per minute. The capillaries of the skin, and prob- 
ably those of the brain, were suffused all the time. There is but a 
step from erethism to acute congestion. 

Treatment. — The first thing is to remove the cause. If it is brain 
work, enforce mental rest ; if it is mental strain from business trou- 
ble, grief, and other emotions, we may palliate by means of sedatives, 
but never by alcoholic liquors. It is much safer co give small doses 
of the bromides during the day, and enough to cause sleep at night, 
if remedies homeopathically indicated will not effect quiet. 

If it is caused by teething, scarify the gums if aconite or chamo- 
milla does not relieve. If it is due to irritating substances in the 
stomach or bowels, expel them by an emetic of warm water, or mus- 
tard and water, or a purge of castor oil. If from worms, give san- 
tonin or naphthalin. Women are generally relieved hj asafoetida, 
valerian, Scutellaria, or bromide of camphor. If there is arterial 
excitement, aconite, gelsemium, veratrum viride, or belladonna. 

In young children, or adults who do not drink them as a bever- 
age, caffeine or theine will act happily, as will cannabis indica when 
the mind is exalted, joyous, and extravagant. If the patient is 
gloomy or irritable, hyoscyamus or hyoscine are very potent remedies. 
Above all, change the surroundings of the patient. Eemove him 
from noise, and to a place of absolute quiet, as soon as possible. 
Allow no tea, coffee, beef, or liquors. A journey on the lake or 
ocean is one of the best sedatives. So is a life in die woods, or by 



886 



THE PRACTICE OF MEDICINE. 



the shore of a quiet lake, and the enjoyment of fishing or rowing. 
It is probable that many cases diagnosed and treated as cerebral 
hyperaemia are really nothing more than cases of functional irritation, 
without any change in the cerebral circulation. 



CEREBRAL HYPEREMIA (Congestion of the Brain). 

Definition. — An abnormal amount of blood in the cerebral ves- 
sels. There are two kinds of cerebral hyperaemia : 

(1) Active congestion, in which a larger amount of blood than 
usual is sent to the brain. (2) Passive congestion, in which the 
blood is not actually increased in the brain, but, owing to obstruc- 
tion, does not return freely through the cerebral vessels, which there- 
fore become charged with blood. This is venous congestion or stasis. 

In active congestion the symptoms are those of excitement. In 
passive congestion the symptoms are those of depression. 



DIAGNOSIS 



Active Congestion. 
Wakefulness, erethism, pain in head, 
intolerance of light, noise, and pres- 
sure. 

Singing or ringing in the ears, sparks 
or spots before the eyes, contraction 
of pupils, heat and redness of face, 
full and strong pulse, throbbing of 
carotids. 

Spontaneous vomiting, grinding of teeth, 
vivid dreams, jerking of the limbs, 
vertigo, convulsions, hypertrophy of 
left ventricle of the heart. 



Passive Congestion. 
Head feels dull and heavy; limbs go to 
sleep; they have a heavy, paralyzed 
feeling. 

Dullness of the senses; pupils dilated, 
pulse small and frequent. Respira- 
tion slow, irregular, or stertorous. 



Nausea, vomiting. Disease of the right 
heart, which tends to prevent the re- 
turn of venous blood from the brain. 



Notwithstanding the great divergence in the prominent symptoms, 
it is often difficult to make a positive diagnosis. When vaso-motor 
irritation is at the bottom of the trouble, these two states may alter- 
nate. Acute congestion may be very transient, as during a fit of 
anger or a paroxysm of coughing. 

The " flushings " at the " change of life " is a brief congestion ; 
but if the patient be very plethoric and the blood-vessels are ather- 
omatous, apoplexy may result from these transient congestions. 



DISEASES OF THE NERVOUS SYSTEM. 887 

Children are more prone to congestion of the brain than adults, 
owing to the thin texture of the skull, the open fontanelles, and the 
unossified sutures, while the softer brain substance exerts a much 
less counter-pressure. 

Active congestion may be caused by the same conditions as irri- 
tability of the brain. It may be caused by the poison of some erup- 
tive disease, as scarlet fever, measles, la grippe, or during the apy- 
rexia of an intermittent fever. Convulsions from congestion often 
usher in these fevers. 

Passive congestion may arise from debility, want of pure air, 
sufficient food, or from exhaustive diseases, diarrhoea, dysentery, 
cholera, and a weak, dilated heart. Finally, it may be caused by 
vaso-motor spasm, closing the arterioles of the brain. 

Treatment. — The two varieties of congestion need an altogether 
different treatment. Active hyperemia needs cool or cooling appli- 
cations to the head, heat to the feet and extremities, and quiet sur- 
roundings, with a cool atmosphere and cool clothing. The stomach 
and bowels must be unloaded of accumulated faecal or indigestible 
matter. Dry-cupping to the back of the neck, and the use of home- 
opathically indicated medicines, or those which oppose physiologi- 
cally the existing condition. 

The remedies according to the law of similia are glonoine, nitrite 
of sodium, ferrum phos., belladonna, hyoscyamus, stramonium, qui- 
nine, cannabis indica, paulliana, aurum, and agaricus. 

Those which physiologically reduce the blood-pressure are aconite, 
gelsemium, veratrum viride, antipyrin, acetanalid, and the bromides. 
I have had the best success in the treatment of all but transient 
hyperemia by the alternation of the two classes of remedies. 

Aconite lx and belladonna 3x act well together. Gelsemium lx 
and glonoine 6x. Veratrum viride lx and ferrum phos. 6c. 

If there is a malarial poison in the system, bromide of sodium 
five grains, and quinine 3x or eucalyptus 2x go well together. Gel- 
semium (tincture) and cannabis indica 3x are very useful when both 
are indicated. Instead of alternating I have often given them mixed, 
and with the happiest results. 

Sometimes atropine 6x or hyoscyamine 6x act with more prompt- 
ness than do the dilutions of the mother drug. In some cases of 
threatening congestion, when convulsions or apoplexy are imminent, 



888 THE PRACTICE OF MEDICINE. 

I do not hesitate to give to an adult five drops of the pure tincture 
of veratrum viride, either by the mouth or hypodermatically. In the 
terrible congestion of the brain which occurs in puerperal women it 
is important to do this. I recall three cases where ten drops of the 
tincture veratrum viride were injected into the thigh. There had 
been several convulsions, there was trismus, red face, eyes blood-shot, 
delirium, etc. In each case, after the second or third injection at 
intervals of an hour, the pulse became soft, trismus relaxed, the 
pulse became normal, consciousness returned, and a rapid recovery 
was made. In other cases, treated with chloroform and morphine, 
or belladonna and hyoscyamus, the favorable change was slow and 
recovery tardy. 

The bromide of sodium is better in many respects than the other 
salts, especially in children. If a teething child is threatened with 
congestion, we are never sure that convulsions may not soon occur. 
If scarifying the gums is not consented to, or thought advisable, and 
if a few doses of veratrum viride lx, or belladonna 2x, do not act 
favorably, give five grains of the bromide of sodium and repeat it in 
an hour. Then to maintain the effect continue the belladonna. If 
an adult of apoplectic tendency, give bromide of lithium or bromide 
of ammonium. Like Hammond and Weir Mitchell, I have warded 
off apoplexy with twenty or thirty grains of either, the bromide 
of ammonium acting best when pain in the occiput is complained of ; 
the lithium salt when the pain is diffused all over the head. Ergot 
is recommended for cerebral congestion from the fact that it has the 
power of contracting the arteries and arterioles. It is especially 
advised in miliary aneurisms of the capillary blood-vessels of the 
brain. The rationale of its action is generally misunderstood. Even 
Hammond, who gives doses of one drachm, does not correctly state 
the condition in which it is useful. It is not useful in any active 
congestion when there is arterial excitement, because with a strong- 
acting heart it will increase the cerebral fullness, for when it con- 
tracts the distal ends of the arteries, the heart's action is increased 
to overcome the resistance. Ergot acts curatively only when the 
heart is a weak heart and the coats of the arteries are relaxed from 
vaso-motor paresis. (When ergot is really indicated in uterine 
hemorrhages the same condition exists.) The patient must be lym- 
phatic ; his face pallid or livid ; his flesh flabby, with distended 



DISEASES OF THE NERVOUS SYSTEM. 889 

capillaries ; under the tongue you will see small aneurisms, a sure 
sign that they may exist in the brain ; the pulse is soft and sluggish, 
showing the same action in the heart. In such cases ergot, acting on 
the vaso-motor centres, causes a slow but permanent contraction in 
the whole arterial system, and gives the heart a normal tonicity. It 
does not require large doses, but the preparation of ergot must be 
good. Our tincture of secale will not do. Squibb's fluid extract, 
or Parke Davis & Co.'s " Normal liquid ergot," or any other similar 
preparation, should be used. Ten to twenty drops every four hours 
is quite sufficient. 

Ustilago (corn ergot) has the same action as rye ergot, and can 
be substituted for it. 

Phoradendron (mistletoe) has been used for the same condition * 

Cimicifuga has a similar action, and when the symptoms corre- 
spond, will be found an excellent remedy, but in small doses, because 
it induces cerebral passive congestion primarily, while ergot and 
ustilago cause it by their secondary action. 

Passive Congestion or Stasis requires quite different treatment, 
for the stasis is mainly in the veins. I am of the opinion that nearly 
all cases of true venous stasis are caused by vaso-motor spasm of the 
arterioles. In such cases, amyl nitrite can be used as a temporary 
palliative. It will relax the contraction while other remedies are 
acting. Nitrite of sodium has a longer duration of action, even 
longer than glonoine. The former can be given in doses of two 
grains of the ix every four hours. The latter in doses of l-200th or 
l-100th of a grain, until its peculiar symptoms indicate that the 
arteries are open to the free passage of blood. It is said that the 
cobalto-nitrite of potassium has a slower and more permanent action 
than any of the above nitrites. The dose is one-tenth to one-fourth 
of a grain every four or six hours. The characteristic indications 
for the nitrites are the small hard pulse, with pallor of the face, cold 
hands and feet, and the symptoms of contracted arterioles. 

When the opposite condition of the cerebral blood-vessels is pres- 
ent, namely : vaso-motor paresis, the arterial coats have lost their 
elasticity, and in this condition, while ergot and similar remedies 
give temporary relief, it is not lasting. 

The object of treatment in passive hyperemia is to keep the blood 
current moving through both veins and arteries, while not allow ing v 



890 THE PRACTICE OF MEDICINE. 

them to be unduly full. Now while belladonna, hyoscyamus, phos- 
phorus, pilocarpine, eucalyptus, opium, and nux vomica are indicated 
for active acute hyperemia by their primary action, their secondary 
effect is the reverse. If we give them, it must be to cause some phy- 
siological effect, when (in low dilutions) they will gently excite the 
circulation, and bring about a normal condition. 

Phosphorus is especially suitable. It is a primary stimulant to 
the gray matter of the brain, and in large doses causing the same 
kind of hyperaemia that is caused by excessive study or any brain 
work. 

But when the hyperaemia has lasted some time, or has been fre- 
quently repeated, the dilated vessels do not contract as they should. 
Hence it causes a stasis. Dr. Hammond values phosphorus very 
highly in this condition. He prefers the phosphide of zinc to any 
other preparation, but gives more than is necessary. The one-eighth 
or one-tenth of a grain deranges the stomach and bowels, while the 
l-100th or l-50th, given several times a day, does not, and is just as 
effectual as larger doses. 

Eucalyptus, when given in large doses, causes flushing of the 
upper part of the body and head, throbbing of the temples, fulness, 
heat, and pain in the head, " a drunken feeling," with excitement, 
vertigo, and afterwards depression of mind and dullness of intellect. 

This picture simulates acute hyperaemia followed by passive stasis. 
Eucalyptus shares with quinine a reputation as an anti-malarial med- 
icine, and when the cerebral congestion occurs from malarial poison- 
ing it can be substituted for quinine in minute doses during the pri- 
mary hyperaemia, and for the large doses when stasis sets in. Dr. 
Hammond says : " The fluid extract has certainly in my hands been 
productive of excellent results." 

There is one condition in which I have used pilocarpine (jabor- 
andi) with benefit. When the hyperaemia occurs from a sudden chill, 
when then the skin is dry and cold, the mouth and throat dry, and 
the pulse feeble, then if one-tenth of a grain of pilocarpine is injected 
under the skin, or twenty drops of the tincture jaborandi given, the 
face and body will flush, a hot perspiration will appear with relief 
to the head. 

As in other portions of the body, if venous stasis continues in the 
brain, especially of children and old people, oedema of the cerebral 



DISEASES OF THE NERVOUS SYSTEM. 891 

tissue obtains. In such cases arsenic is the chief remedy. Its pri- 
mary and secondary action is like phosphorus, except that while 
arsenic leads to oedema, phosphorus leads to fatty degeneration of 
the arterioles. Dr. Hammond, like Hahnemann, says it is indicated 
when the congestion is the result of extreme mental exertion with 
great anxiety of mind. 

In passive congestions of old people Dr. Hammond recommends 
the cautious use of alcoholic stimulants. I have found small quan- 
tities of Tokay to act admirably. The same authority finds sul- 
phuric ether very beneficial ; a teaspoonful inhaled, or fifteen drops 
given by the stomach several times a day. A few drops of opium 
lx is suitable when the patient is stupid, indifferent, and somnolent. 



CEREBKAL ANAEMIA. 

Definition. — A condition in which the quantity of blood in the 
brain is either reduced below the normal standard, or is impover- 
ished. The first-named condition may be due to direct loss of blood, 
to deficient action of the heart, to impaired nutrition, or to some 
cause preventing the due access of blood to the brain ; the second to 
disease of some organ concerned in haematosis, or to a general ca- 
chexia. The two states very often coexist. (Hammond.) 

There is a temporary anaemia due to such depressing emotions as 
fear, or shock, or sudden grief, when the face will blanche, the hands 
and feet become cold, and syncope result. It is probable, however, 
that a partial failure of the heart to throw blood to the brain is the 
real condition. Cerebral anaemia may be suddenly induced by pro- 
fuse hemorrhage, by lessening the whole volume of the blood ; the 
pulse is feeble and thread-like ; there is vertigo, ringing in the ears, 
blindness, and feeble respiration. In gradual cerebral anaemia these 
symptoms are present, but in a less degree. There is headache in 
a small spot ; a sense of constriction around the head, over the eyes ; 
vertigo on rising from a sitting or lying position. Loud noises are 
painful. The pupils are dilated, sluggish. The retina is sensitive 
to light. There is paresis of the ocular muscles, reading produces 
pains in the eyes and in the head. The use of glasses is often advised, 
but give only temporary relief. The complexion is pale, lips color- 
less or redder than normal. There is drowsiness, except on lying 



892 THE PRACTICE OF MEDICINE. 

down, when there is sleeplessness ; such patients often sleep better 
sitting, or lying with the head high. 

They have illusions, hallucinations, and melancholia. Local par- 
alysis may result. In children and adults, after wasting diseases, 
such an amount of cerebral anaemia may result as to simulate, in chil- 
dren, hydrocephalus — and in adults, dementia. Impoverished blood, 
toxaemia, chlorosis, malnutrition, and malaria, may be the cause of 
the anaemia. In all cases, long-continued, the deficient supply of 
blood interferes with the nutrition of the brain, and with its normal 
functions. Authorities all admit that it is difficult to diagnose this 
condition from cerebral congestion, but Bauduy (" Diseases of the 
Nervous System ") goes too far when he asserts that " the sympto- 
matic manifestations of hyperaemia and anaemia are identical, and 
furnish no clew by which we can recognize and differentiate these 
two conditions of diametrically opposite pathological character." If 
he had qualified this by saying passive hyperaemia he would have 
been correct, for I cannot imagine it possible to mistake active con- 
gestion for anaemia. Hammond says, we must make a diagnosis by 
" a careful inquiry into the etiology ; by the fact that drowsiness, 
not wakefulness, is a prominent symptom ; that the pupils are dilated^ 
not contracted ; that the pain is limited to a small part of the head, 
instead of being general ; that it, and the vertigo, is increased by 
the erect position, and diminished by lying down ; that the ophthal- 
moscope shows retinal anaemia ; that the face is pale and the skin 
cold ; the pulse weak and feeble ; that bellows murmurs are heard 
at the base of the heart and in the veins of the neck ; that stimu- 
lants and tonics mitigate these symptoms." 

Notwithstanding all this, there are anomalous cases, in which 
these symptoms are the result of passive anaemia, making a diagnosis 
very difficult. 

Both Bauduy and Hammond warn physicians not to treat hyper- 
emia for anaemia, and vice versa, or dangerous consequences may 
result. Here lies one of the dangers of treating disease according to 
pathological theories ; and one advantage to our school, of treating 
the symptoms when we are not sure of the pathological condition. 
The only harm we can do, is, that we allow the disease to go on with- 
out interference. 

Treatment. — The first step is to ascertain the cause. If it is 



DISEASES OF THE NERVOUS SYSTEM. 893 

malaria, remove the patient to a non-malarial region. If malnutri- 
tion, order the proper food and hygiene. If hemorrhage, arrest it. 
If from lactation, order the child weaned. If from imperfect diges- 
tion, treat the digestive organs. There is one cause of chronic func- 
tional cerebral anaemia, especially when due to vaso-motor constric- 
tion, that has been greatly overlooked, namely, the influence of reflex 
irritation on the vaso-motor centres. This malign influence generally 
starts from those outlets and orifices which issue from the pelvic 
cavity. If there exist in them constrictions or irritable growths, 
all means used for the cerebral anaemia will fail, until those causes 
of irritation are removed. This fact has been recognized by a few 
advanced thinkers, but to Dr. E. H. Pratt is due the honor of call- 
ing wide attention to it, as it has never been done before. When all 
rational procedures have failed to restore the normal equilibrium of the 
cerebral circulation, the rectum, vagina, uterine cervix, urethra, and 
bladder should be thoroughly examined, and any source of irritation 
found there removed. In choosing medicines we should first inquire, 
what drugs cause cerebral anaemia ? There are two classes, namely : 

(1) Those which cause it by acting on the vaso-motor centre, as the 
bromides, ergot, hydrastis, zinc, baryta, digitalis, nicotine, strych- 
nine, caffeine, lobelia. These, and many other less important drugs, 
cause cerebral anaemia by constricting the arterioles in the brain ; 

(2) those which decrease the amount of blood in the brain by 
depressing the action of the heart — among which are gelsemium, 
aconite, veratrum viride and veratrum album, cactus, and other car- 
diac poisons. All these are homeopathic to cerebral anaemia ; but 
right here allow me to state a singular fact which has been observed 
by many of our school: namely, that the drugs most exquisitely 
homeopathic to a pathological state very often disappoint us as cur- 
ative agents. Why, I will not attempt to explain. Certain it is, 
that the bromides and ergot are not successfully used in minute 
doses in cerebral anaemia, and they are types of this class. Hart 
(" Diseases of the Brain ") recommends arsenic, but arsenic does 
not cause cerebral anaemia by vaso-motor spasm, but by causing an 
oedema of the brain which presses on the cerebral vessels ; or by 
injuring the integrity of the blood. He also recommends veratrum 
album, but only when exhausting diarrhoea or cholera causes a dim- 
inution in the volume of the blood. 



894 THE PRACTICE OF MEDICINE. 

Hahnemann recommends camphor, which doubtless causes vaso- 
motor spasms ; but he advises it only when exhausting discharges, 
or " shock " causes syncope, and he nowhere advises minute doses 
— which seems contradictory to his general practice. Camphor is 
only suitable in transient cases where a shock of some kind, or some 
violent congestion of some other organ, takes the blood from the 
brain. I do not think we will ever find the " exquisitely " homeo- 
pathic remedies useful in sudden cerebral syncope. My experience 
is that we have better success with those which act physiologically 
by increasing the amount of blood in the brain. These medicines 
are those which relax vaso-motor spasm, like amyl nitrite, soda 
nitrite, glonoine, or alcohol. The inhalation of a few drops of amyl, 
the one-hundredth of a grain of glonoine, two or three grains of soda 
nitrate, a few drops of camphor, or a spoonful of brandy or alcohol, 
are generally sufficient, with the aid of the recumbent posture, to 
cause the normal amount of blood to enter the brain. In some cases 
it is better to place the head lower than the body ; or to ligate the 
lower extremities ; or apply hot applications to the heart. The treat- 
ment of the more persistent cases of cerebral anaemia, when it arises 
from loss of blood, is to give meat juices, beef tea, eggs, etc. One 
of the best of all beef extracts is Valentine's meat extract. It is 
made from the blood of beef, and the expressed juice of the meat. 
It offends neither taste nor smell, and is pleasantly sweet and aro- 
matic. A teaspoonful is equal to an ounce of ordinary beef tea. 
The recumbent position is imperative, until the anaemia is better. 
Passive exercise, by massage, is the only exercise to be permitted. 
China (cinchona) is doubtless the best medicine, but I am frank 
to assert that I never found the attenuations of any value, except 
the lx, in twenty or thirty-drop doses, and then the alcohol played 
an important part in the cure. The tincture in ten-drop doses in a 
spoonful of Tokay, port or brandy, is very efficient in all cases. In 
some cases only a few drops of brandy or Tokay are well borne at 
first. If there is a malarial cachexia, arsenite of quinine is very 
efficacious, also natrum mur., and arsenite of iron. In the cerebral 
anaemia of chlorosis, permanent improvement will not come until the 
general anaemia is improved. It is useless to dose the patient with 
iron, because iron is rarely indicated in real chlorosis. Arsenic, 
strychnine, and phosphorus are the real remedies, aided by pure air, 



DISEASES OF THE NERVOUS SYSTEM. 895 

good food, cheerful surroundings and rest. Hammond recommends 
the inhalation, three times a day, of three drops of amyl in the treat- 
ment of severe chlorosis. It opens the cerebral blood-vessels, and 
allows the blood to enter therein, and in that way increases the nutri- 
tion of the brain ; a suggestion which I have found of positive value. 
One of the best medicines to keep open the cerebral vessels is aurum. 
I have used it extensively in all cases of real anaemia of the brain, 
and am certain it aids in giving nutrition by causing the blood to 
fill the brain. It dissipates the drowsiness, melancholia and brain 
weariness. Its effects last longer than the nitrites or alcohol. One 
tablet, containing the one-hundredth or one-fiftieth of a grain, given 
three times a day, is sufficient. I prefer the muriate of gold and 
sodium to any other preparation. Zinc is the sovereign remedy for 
the cerebral anaemia of children, brought on by exhausting diar- 
rhoea, fevers, or from repeated cerebral congestions. This condition 
is the " hydrocephaloid state" described by Marshall Hall. In some 
cases picrate of zinc, 3x or 6x, is more potent than zinc alone, 
because picric acid causes a more profound cerebral paresis. It 
ought to be good alone, and may prove so in some instances, but I 
like the compound better. The phosphide of zinc, efficient in pas- 
sive Iryperaemia, is useful in anaemia, but in smaller doses, 3x or 6x. 
In the " brain fag " of literary and business men these remedies are 
unsurpassed. I have had brilliant results from arsenite of copper, 
arsenite of strychnine, and arsenite of gold. The indications must be 
taken from our provings of the elements of which they are composed. 
The practical physician will appreciate their value when he tests them. 
Hydrastis has been my favorite remedy for years in cerebral anae- 
mia because it is homeopathic not only to the state of the brain, 
but to the faulty digestion and assimilation which often attend, or 
may be the cause of, cerebral anaemia. The tincture, or lx, of hydras- 
tis, or hydrastin 3x, may be used, but I prefer the white alkaloid in 
the form of the hydrastia muriate. This is the most potent combin- 
ation of that drug. The 3x trituration — one grain before meals — 
acts well, but I prefer a preparation like the following : Hydrastia 
mur., one grain ; dilute muriatic acid, one drachm ; pepsin purum, 
one drachm ; glycerine, one-half ounce ; distilled water, three and a 
half ounces. Dose, a teaspoonful before meals. The hypophosphite 
of soda in doses of one to three grains, according to the age of the 



896 THE PRACTICE OF MEDICINE. 

patient, acts happily when there is great nervous prostration. If 
there is much emaciation and mal-nutrition, give an emulsion of cod- 
liver oil and hypophosphites ; and to each teaspoonful add ten drops 
of tincture of saw palmetto. 

A common cause of cerebral anaemia is cardiac weakness. The 
heart is simply a pump, which, in its normal state, forces a certain 
.amount of blood with a certain pressure, and, when a person is stand- 
ing, to a certain height. If the heart is injured in its valves, or the 
radical force which moves it is deficient, the amount of blood which 
it throws to the head will be less than normal. 

Hypertrophy, with dilatation, stenosis of the valvular orifices, or 
aortic aneurism, will cause cerebral anaemia. 

In such conditions we must increase the forcing power of the 
heart. If veratrum or arsenic or nux vomica does not increase 
it, digitalis, strophanthus, anhalonium, or cactus should be used in 
doses of five drops of the mother tincture three times a day. The 
addition of one drop of glonoine, lc. or 2c, to a dose aids greatly 
the beneficial action of these medicines. 

HEADACHE. 

Definition. — Cephalalgia means simply pain in the head, but it 
should be divided into two kinds, namely : (1) Headaches depend- 
ing on causes within the brain ; and (2) headaches depending on 
causes external to the brain. These two divisions must be subdi- 
vided as follows : 

INTRA-CEREBRAL HEADACHES. 

(1) Cerebral Anaemia. 

(2) Cerebral Hyperaemia. 

(3) Sympathetic Headache. 

(4) Dyspeptic, Bilious, or Sick Headache. 

(5) Neurasthenic or Nervous Headache. 

(6) Congestive Headache. 

(7) Plethoric Headache. 

(8) Arthritic or Gouty Headache. 

(9) Toxaemic Headache. 

(10) Organic Headache. 

(11) Headache of Childhood and Old Age. 



DISEASES OF THE NERVOUS SYSTEM. 897 

EXTRA-CEREBRAL HEADACHES. 

(1) Rheumatic Headache. 

(2) Periosteal Headache. 

(3) Neuralgic Headache. 

It may seem an unnecessary refinement to designate so many 
kinds of headache, but I am satisfied of its importance. The time 
has passed when we can ignore the pathological basis of diseases. I 
assert the truth, that as believers in the law of Similia as a general 
guide to the administration of medicines in diseases, it is more 
important for us to know the pathology of disordered states than it 
is for physicians who do not believe in our law of cure. 

The so-called regular school can treat headaches only by hygiene, 
antipathic medicines, chemical agents, derivatives and palliatives. 

We can adopt all the above means, and in addition, we have an 
immense advantage over all, by resorting chiefly to the medicines 
indicated by the law of Similia. I am aware that a few of our 
school who imagine it their duty to adhere to the strict interpreta- 
tion of Hahnemann's directions to select the remedy by the totality 
of the mere symptoms — ignoring the pathological cause of those 
symptoms, will scout the idea of selecting a remedy for headache in 
any other way ; but my knowledge of the action of drugs enables 
me to assert, without fear of contradiction by scientific men, that 
two individual drugs may cause a group of identical symptoms, yet 
the pathological state may be altogether different. In view of this 
fact I contend that we should be acquainted with the pathological 
actions of drugs, in order to differentiate between medicines, the 
symptoms of which are very nearly similar. 

Our knowledge of the pathology of drugs is yet limited, but the 
time will come when it will equal our knowledge of their symp- 
tomology. By the pathological effects of drugs, I mean their physio- 
logical effects carried to an abnormal degree. Therefore, when 
giving the treatment of the above mentioned varieties of headache, 
I shall give not merely the symptoms, as too many of our text-books 
do, but also the indications for the hygienic, chemical, antipathic, 
and physiological, as well as the homeopathic uses of the medicines 
recommended, as correctly as it is possible to do, with our present 
knowledge of their action. 



898 THE PRACTICE OF MEDICINE. 

Headache from Cerebral Anaemia. — Haller computed that the 
brain normally receives one-fifth of the blood in the body. Dr. Day, 
in his invaluable work on "Headaches," says: "In the brain the 
demand for healthy blood is two-fold. In common with all the tis- 
sues of the body it requires a due supply of nutrient material for the 
maintenance of its structural integrity and functional efficiency, but 
a more urgent demand is for the oxygen which is conveyed by the 
hemoglobulin of the red corpuscles." . . . "Whenever the red 
corpuscles with their constant supply of oxygen are not passing 
through the capillaries of the brain in sufficient number, we have a 
cerebral anaemia." The blood itself may be of due composition, but 
virtual cerebral anaemia may arise from a weak action of the heart, 
functional or organic in origin, through the slow transmission of 
blood along the vessels, or the cerebral blood-vessels may be diseased 
and obstruct the passage of blood by loss of elasticity or actual nar- 
rowing, as in advanced life. 

There is a general and partial anaemia of the brain. Local cere- 
bral congestion may occur in one portion of the brain, causing anae- 
mia of other portions. General anaemia and a cachectic state of the 
blood induce cerebral anaemia, which may cause a double set of 
symptoms to appear. 

I have already, in the article on " Cerebral Anaemia," entered as 
fully into the symptoms as my space will permit. I shall therefore 
mention only the most characteristic symptoms of the anaemic head- 
ache. These are : fits of depression and low spirits, f earfulness and 
timidity, dread of things unlikely to happen, sleeplessness at night 
and drowsiness by day. The pain is on the top of the head, which 
feels hot and burning to the hand. The pain is not throbbing or 
bursting, but of a gnawing, scraping character. (One exception to 
this is that after great loss of blood, patients often complain of a 
pulsating or " hammering in the top of the head.") 

The tongue is generally furred at the back if the condition has 
been of long duration and there is flatulence and constipation. The 
colon is loaded and torpid from deficient muscular contraction, which 
is common in all forms of impaired functional activity of the brain. 
The pupils may be dilated or contracted. An excellent diagnostic 
measure is the use of the ophthalmoscope. If anaemia is present it 
will reveal pallor of the optic disc and dullness of the choroid. The 



DISEASES OF THE NERVOUS SYSTEM. 899 

blood-vessels of the retina are generally pale, and the disc is of a 
pale and waxy hue. 

The pulse is weak and small ; slight pressure obliterates it. I 
have seen cases where the pulse was very slow and weak — not over 
50 per minute — without any organic heart disease. Often the pulse 
is rapid, 120 per minute. A weak, paretic heart may cause the two 
extremes of pulse, and is often the chief cause of cerebral anaemia. 

An anaemic brain is often the principal cause of chronic alcohol- 
ism. It causes a desire for stimulants, which give only a temporary 
relief, and lead to the habit of using alcoholic liquors. This leads 
also to an inordinate craving for and abuse of coffee. Many patients 
are "fit for nothing" in the morning until they have swallowed a 
cup of strong coffee, which temporarily congests the brain. Cere- 
bral anaemia readily leads to the opium habit, for the same reason. 
Opium or morphine should be given such patients only as a pallia- 
tive and at long intervals. 

The headache from cerebral anaemia is not generally paroxysmal ; 
it is wearing and continuous. But paroxysms may be caused by 
fatigue, excitement, and mental labor. These paroxysms are usually 
preceded by flushing of the face, due to the flushing of the brain, 
while under excitement. But this is followed by the opposite con- 
dition, of empty blood-vessels. Unless narrowing of the blood- 
vessels exists from atheroma, the coats of the cerebral vessels are 
relaxed, and readily dilate under excitement or from the smallest 
quantity of alcohol or stimulant drugs. This is the reason why those 
who have anaemia of the brain cannot take wine, coffee, or opium, 
even in small quantities, without flushing of the face. 

Treatment. — The restoration of the brain circulation in cerebral 
anaemia does not require the use of drugs so much as good food, 
pure air, and pleasant surroundings. Pleasant society, cheerful 
scenery, out-of-door sports, hunting, fishing, and other recreations 
are necessary. No mental labor should be undertaken, no night 
work, no artificial stimulants ; the patient should go to bed early — 
as early after a late supper as possible, and he should lie in bed in 
the mornings as long as he desires. 

All weakening discharges should be checked. The food should 
be digestible and nutritious. Fats like bacon and butter, meats 
which are tender and contain red blood, and the most nutritious 



mO THE PRACTICE OF MEDICINE. 

"cereals and vegetables should form the chief diet. If the bowels are 
confined they should be opened by the use of prunes, peaches, figs, 
dates, bananas, apples, etc. But little coffee should be allowed. 
No wine except a little good sound claret or Tokay. If the bowels 
are loose, with passages of half -digested food, they should be cor- 
rected by the use of bismuth or phosphoric acid, combined with pep- 
sin or pancreatin. If meat is not digested, use the former ; if the 
starch, use the latter. Papoid acts in both conditions. 

A good preparation is " Maltine with pepsin and pancreatin." 
" Forbes's Diastase " favors the digestion of starch. If milk is used 
it should be violently shaken ; this makes it much more digestible. 
Nux vomica, strychnine, and hydrastin all increase the power of 
digestion and assimilation ; so do muriatic, nitro-muriatic, and phos- 
phoric acids. If the colon is obstinately torpid give a pill of one- 
eighth of a grain of aloin, or aloin one-eighth with strychnine one- 
hundredth of a grain. A good laxative pill is nux vomica one-fourth 
of a grain and hydrastin one-fourth of a grain. 

Arsenic is one of our best remedies in cases of lientery, where 
the food is only half digested. The best preparation is the arseniate 
of iron 2x. " Levigo water," from a spring in the Tyrol, contains 
this combination. Give a teaspoonful in half a glass of water after 
each meal. This drug is indicated in general anaemia, where the 
whole mass of blood is poor in haemoglobin. 

The 3x of hypophosphite of iron is sometimes preferable. We 
itave in this country many ferruginous springs which can be used 
with benefit, but the patient must be cautioned to use them sparingly. 

There is no medicine in our Materia Medica better adapted to 
the treatment of headache from anaemia of the brain than cimicifuga. 
It corresponds to the depressed mental condition ; to the melancholy 
and irritability ; to the condition which verges on delirium tremens, 
and to various painful sensations so characteristic of anaemia. (Gym- 
nocladus has similar head symptoms.) It resembles platina in many 
points, but the head symptoms have some notable divergence. One 
example is that platina has a downward pressure on the vertex, while 
cimicifuga has an upward pressure as if the top of the head was being 
forced off. 

When the anaemia of the brain depends upon a weak heart, the 
blood itself being normal, cardiac tonics are useful. Digitalis, five 



DISEASES OF THE NERVOUS SYSTEM. 901 

drops three times a day ; strophantus, cactus, or collinsonia in the 
same dose, will soon impart sufficient propelling power to the heart. 
If the heart is thin and dilated, always add to each dose one-hun- 
dredth or one-sixtieth of a grain of strychnine or one-eighth of a grain 
of extract of nux vomica or ignatia. 

During a paroxysm of anaemic headache the patient should not 
attempt to sit up, but must lie with the head low, and have warm or 
hot applications made to the vertex. In this position, a few whiffs 
of amyl nitrite, two drops, will remove the pain as if by magic, or a 
tablet of one two-hundredth or one-hundredth grain of glonoine will 
do the same. It can be repeated in one or two hours. 

If the pain is persistent, a tablespoonf ul of champagne every half- 
hour acts admirably. 

Veratrum album is indicated 3x or 6x when the face is pale, with 
cold nose and forehead and cold sweat on the head. Arsenicum 3x 
is indicated when there is present the extreme restlessness peculiar 
to the drug. Both can be repeated every fifteen minutes. 

Aurum is one of our best remedies to prevent such paroxysms if 
they are frequent. Give a tablet of the 2x three times a day continu- 
ously for weeks. I prefer the chloride of gold and sodium, the bro- 
mide of gold, or the arseniate of gold. Platina and argentum act 
like gold, and may be as efficient if indicated by their symptoms. 
If rigidity or narrowing of the blood-vessels is present, iodide of 
soda, three grains before meals, has been productive of good results. 



HEADACHE FROM CEREBRAL HYPEREMIA. 

In my article on hyperaemia of the brain I have fully discussed 
this condition, and will not add to it, except to mention a few rem- 
edies which have been found useful during the paroxysm. Persons 
subject to these paroxysms are generally those whose habits are sed- 
entary, who eat too much, and drink too much coffee or wine, or are 
prone to fits of anger or mental excitement. During the paroxysms 
the head is hot, the face flushed, the temporal arteries throb, the 
eyes are red, and the pulse is hard and full or hard and small. In 
the former case no remedy is so effectual as veratrum viride, one 
drop of the tincture every half-hour — one or two doses often reliev- 
ing the headache. If the pulse is small, wiry, and hard, aconite is 



902 THE PRACTICE OF MEDICINE. 

specific. The one-tenth of a drop every half-hour gives prompt 
relief. 

Gelsemium, in the same dose, acts equally well, but instead of the 
anxiety and mental restlessness of aconite there is a stolid, quiet, 
flushed face, and sleepy look in the eyes. Belladonna, agaricus, hyos- 
cyamus, nux vomica, lachnanthes, cactus, cannabis indica, glonoine, 
ignatia, and phosphate of iron are primarily indicated, and they 
should be prescribed in the 3x or 6x attenuations. If the attack 
has been brought on by eating to excess, the stomach should be 
emptied immediately by an emetic of mustard-water, warm water, 
or one-eighth of a grain of apormorphine ; very prompt, easy vomit- 
ing is caused by the latter if injected hypodermically. At the same 
time, if the feet are cold, they should be immersed in hot mustard- 
water or a hot-water bag applied. 

We cannot deny the value of the bromides as palliatives in hy- 
peraemic headaches. Their use is as justifiable as heat to the feet 
and cold to the head. They cause a temporary contraction of the 
blood-vessels of the brain, and instead of interfering with the action 
of the similimum they prepare the way for its efficient use. 

For quick results in severe cases I prefer the bromide of lithium 
(ten grains) ; next in value is the sodium salt (fifteen grains), or, 
in nervous women, the mono-bromide of camphor (one-fourth of a 
grain). Give a single dose, and follow it by the appropriate remedy. 
Antipyrin lx, ten grains every half -hour, has had good effects in 
some cases, but five grains of the crude drug is frequently given, 
with quick removal of the pain. 



SYMPATHETIC HEADACHE. 

There are almost as many kinds of sympathetic or reflex headache 
as there are organs in the body, but the principal organs that cause 
headache are the liver, stomach, colon, rectum, uterus, ovaries, and 
the sexual organs in general. A good example of reflex headache 
is when a decayed tooth causes an intense pain all over one or both 
sides of the head ; or when swallowing ice, or eating ice-cream, sets 
up an intense headache as soon as it reaches the stomach. 

In the headaches from irritation of visceral organs the irritation 
is conducted along the pneumogastric and great sympathetic, until 



DISEASES OF THE NERVOUS SYSTEM. 903 

It reaches the brain. The sympathetic headache most often met with 
in practice is the menstrual (ovarian or uterine). 

Menstrual headache occurs before, during, or after the flow. The 
flow may be normal, scanty, or too profuse. It is not the uterus in 
such cases that is generally at fault, but the ovaries. I believe it 
occurs oftenest in unmarried women, and I know of many instances 
where such headaches, lasting years, have disappeared after marriage. 
There is an evident reason for this which need not be explained. It 
very often returns at the climacteric period and lasts until the final 
cessation of the menses and sometimes long after. It usually affects 
the vertex, occiput, and temples. 

There is one kind of headache that is certainly dependent on uter- 
ine irritation — namely, when a narrow or bent cervix causes the 
menses to flow with great difficulty and local pain. This variety can 
be cured only by dilating and straightening the cervix, as several 
cases in my records attest. 

When the headache is caused by scanty menses, depending on 
ovarian paresis, ifc can be cured by conium, sepia, graphites, aurum, 
eocculus, asarum, senecio, and sanguinaria, selected according to the 
symptom. There is another class of remedies of which we have no 
satisfactory proving, but of which the physiological effects are to 
increase too scanty menses or cause them to appear when delayed. 
These medicines are often more potent in the cure of headaches from 
such cause than those above mentioned. 

They are, senecin (one grain three times a day), apioline (a cap- 
sule three times a day), bin-oxide of manganese (two grains three 
times a day), pulsatilla (five drops three times a day), sabina (five 
to ten drops three times a day), sanguinaria (five to ten drops three 
times a day), oxalic add (one-eighth to one- fourth of a grain three 
times a day), and hedeoma (thirty drops of the tincture three times 
a day). The faradic current applied to the ovaries and uterus will 
often increase a scanty flow. 

All these should be taken for a week before the menses, until 
they return in normal quantity. If the menses are too profuse, 
sabina, secale, carbonate of calcium, china, platina, trillium, aurum, 
crocus, hydrastis, thaspi, and all the medicines in the second class 
mentioned for scanty menses, are useful in doses varying from ten 
drops of the tincture (hydrastis, trillium) to the third attenuation 



904 THE PRACTICE OF MEDICINE. 

(platina, aurum). All the physiological emmenagogues, when used 
for menorrhagia, should be given in the 1st, 2d, or 3d attenua- 
tion. 

There is a kind of headache, generally occipital, usually follow- 
ing menstruation. The menses may be scanty or profuse, but dur- 
ing and after the flow there exists a sexual hyperesthesia (erotism, 
or erotomania). There are doubtless many more such cases than we 
are aware of, for the natural modesty of unmarried women does not 
allow them to disclose the fact. I have treated many such cases, 
and I have found that bromide of camphor, one-eighth to one grain 
several times a day, cured some cases promptly. Five cases on my 
records were cured by bromide of ammonium. The pain was occip- 
ital, there was insomnia, genital irritation (pruritus), and very pro- 
fuse menses with ovarian pain. Five grains four times a day, given 
live days before the menses, and so long as they continued, made the 
flow normal, prevented the sexual erethism, and palliated the ova- 
rian soreness. 

Platina is homeopathic to the same symptoms, yet it has failed in 
all my cases but one. Why, I do not know. 

Salix niger, a tincture made from the buds of the " pussy " or 
" black willow " is a physiological anaphrodisiac. It acts happily 
for a condition similar to that cured by bromide of ammonia. The 
dose should be fifteen to thirty drops four times a day, before and 
during the menses. 

Salicin, the alkaloid of white willow bark, is said to possess the 
same properties, and has cured similar cases, in doses of one to three 
grains given as directed for salix niger. 

There are two remedies I ought to mention for headache from 
scanty menses. These headaches are marked by heaviness in head. 
The face is cold, also the feet, hands, and body, with shivering, and 
a small, feeble, or wiry pulse. In such cases the inhalation of a few 
drops of amyl nitrite will cause the menses to appear normally, and 
dissipate all the other symptoms. A dose of the one-hundredth or 
one-fiftieth of a grain of glonoine will have the same effect. 

Hot gin and water is a popular remedy in such cases. It acts as 
does amyl and glonoine, by dilating the arterioles, and filling the 
capillaries of the body. Some of its effect may be due to the oil from 
Juniper berries which are distilled with the gin. 



DISEASES OF THE NERVOUS SYSTEM. 905 



BILIOUS -DYSPEPTIC OR GASTRIC -HEADACHE. 

This is often called "sick headache," because vomiting occurs 
when the pain is at its height, and dispels the pain as if by magic. 

" No headache ought to be called bilious unless there is so copious 
a secretion of bile that it either accumulates in the duodenum to 
regurgitate into the stomach, or causes the skin to turn yellow from 
its absorption into the blood." (Day on " Headache.") A genuine 
bilious headache is less common among women than men, who com- 
mit greater excesses in eating and drinking. Young people of both 
sexes are liable to it. The pain comes on in the morning after a 
heavy meal the night before, or after drinking too much wine ; or 
it succeeds after a heavy midday meal, if the person is not accus- 
tomed to it ; or if the food is hurriedly eaten, and exertion and 
fatigue follow it. The pain occupies the whole forehead and top of 
the head, which feels hot and burning. The face is flushed, and the 
temporal arteries throb, A hot room, or stooping, brings on nau- 
sea, and aggravates the pain. 

If the patient avoids taking food he manages to get through the bus- 
iness of the day, but when evening arrives, if he attempts to eat, the 
pallid face is exchanged for one of vascular excitement, and throbbing 
headache, followed by a violent attack of vomiting, after which he 
suddenly and unexpectedly falls asleep, and wakes next morning* 
well ; this headache may continue for several days, unless something 
is given to remove all the fermenting, undigested matter from the 
stomach and soothe the irritated gastric mucous membranes. 

Treatment. — The radical cure of these gastric headaches requires 
that the patient shall change his mode of life. He must not indulge 
in rich and indigestible food, or alcoholic liquors. Unless he does 
this we can only palliate the severity of the attack and each repeated 
attack will leave him in a condition more susceptible to others. The 
immediate or palliative treatment of an attack, like the one described 
brought on by improper food, should consist in the removal of the 
offending mass in the stomach. If there is nausea, let the patient 
drink sufficient warm alkaline water to produce emesis. In old peo- 
ple and children, an overloaded stomach causes such sympathetic 
cerebral irritation that convulsions or apoplexy may result, and we 
must unload the stomach quickly. No remedy will do this as quickly 



906 THE PRACTICE OF MEDICINE. 

as apomorphine — one-twentieth of a grain for a child, and one- 
tenth or one-fifth for an adult. 

When the stomach is empty then we can give the appropriate 
remedies, which are generally nux vomica or bryonia, iris or chion- 
anthus. 

Sometimes it is only necessary to give some chemical or antiseptic 
antidote to the acid or ferment developed in the undigested food in 
the stomach. The laity understand this and resort to bicarbonate 
of soda, Tarrant's seltzer, or Husband's magnesia, with satisfactory 
results. I have used sulphite of soda in twenty-grain doses, giving 
immediate relief, and the bromide of strontium in the same quantity 
ought to be an admirable remedy, for it arrests the acid eructations 
and the pyrosis, antidotes the fermentation and the gases of decom- 
position ; while the bromide constituent will promptly relieve the 
pain and congestion in the head. Sub-gallate of bismuth, five grains 
every two hours, is perhaps more useful. 

There are persons who do not seem to be able to vomit — the 
retching efforts are fruitless. For such, the rapid-acting bitter 
waters (Rubin at or Frederichshall) are appropriate. Tarrant's selt- 
zer aperient (Rochelle salts and bicarbonate of soda) is a pleasant 
effervescing aperient, and will remove the fermenting food in an hour 
•or two. 

If the patient is so anxious to be cured that he will be temper- 
ate in his diet, we can restore the tone of his digestive apparatus by 
giving him a tablet of nux vomica (one-tenth of a grain) and bis- 
muth (two grains) before each meal, and a spoonful of maltine with 
pepsin and pancreatin after meals. If the liver is torpid, the skin 
muddy and yellow, and digestion slow, five drops of dilute nitro- 
muriatic acid before meals and a drop of nux vomica Ix after meals, 
will cause rapid improvement. 

There is an occipital headache, reflected from a congested liver, 
which is sometimes rebellious to treatment. The pain is so severe 
as to be mistaken for occipital neuralgia, but is so evidently reflex 
that we can relieve it only by a sedative action on the stomach, and 
a restoration of the functions of the liver. We may prescribe day 
after day according to the mere symptoms, but we shall not benefit 
the patient until we give a physiological remedy. My experience 
has been that one or two grains of mercurius dulcis or blue mass, at 



DISEASES OF THE NERVOUS SYSTEM. 907 

night, followed by half a tumbler of Eubinat water in the morning, 
will remove the headache more completely than any other medication. 

The same result may sometimes be as quickly accomplished by 
giving one-tenth of a grain of euonymin, leptandrin, irisin, or pod- 
ophyllin before each meal and at night. The addition of three to 
five grains of subnitrate of bismuth, before meals, adds greatly to 
their efficiency. 

Chelidonium, carduus, sanguinaria, eupatorium, juglans myrica, 
Phytolacca, ptelea, and triostium are sometimes indicated in bilious 
headaches. Salicylate of soda is reported to have cured many cases. 

Congestive Headache does not differ materially from active hyper- 
emia of the brain, and the treatment is the same. 

Headache from Plethora requires in most cases only a low diet — 
abstinence from all red meats and malt liquors, with enough Congress 
or Hathorn water to keep the bowels open if they are sluggish. One 
drop of veratrum viride three times a day is the only medicine nec- 
essary. 

HEADACHE FROM EYE -STRAIN. 

Much has been written since 1874 in regard to the relation of 
ocular defects to headaches, when Dr. Mitchell first directed atten- 
tion to the cerebral results of eye-strain ; hence it is important to 
consider for a moment his present views in regard to the relation of 
eye-strain to the production of permanent headache in the sense in 
which it has been defined in this article. " I have rarely seen very 
constant headaches due to eye-strain," writes Dr. Mitchell. "The 
intra-cranial distress from eye-strain comes and goes, and if the 
trouble is typically hemi-crania it is not apt to be caused, even if it 
may be intensified, by defective eyes. I have sometimes, however, 
had a clinical suspicion that it is possible for imperfect eyes, long 
used to excess without correction, to give rise to a condition of occip- 
ital headache, which may be called permanent in the sense that it 
continues for years to survive the cause." This suggestion embodies 
an interesting explanation of some of the types of permanent head- 
aches, for, of course, no reference is now made to the fact, which 
seems perfectly well established, that from forty to fifty per cent of 
the cases of functional cephalalgia are largely amenable to the treat- 
ment of refractive defects and insufficiencies of the ocular muscles. 



908 THE PRACTICE OF MEDICINE. 

Another very important point attaches to this clinical suspicion — 
namely, the occasional apparent inefficiency of correcting an ocular 
defect when, other causes for headache having been eliminated, it 
seems as if it ought to be the means to bring about relief. Once 
more to quote Dr. Mitchell : " Under these circumstances the mis- 
chief has lasted long enough to leave in the brain tissues some last- 
ing result of a too-protracted strain, and we have as a consequence 
either permanent or very frequent headache. " His surmise is that, 
under these circumstances, the centres affected are left in an altered, 
perhaps congested, state, or with a tendency readily to become con- 
gested even by the reasonable use of the eyes. The evident prophy- 
lasis is the correction of ametropic eyes, or, more properly, astigmatic 
eyes, during the formative period of life, when the degree of the de- 
fect warrants interference. 

Some dispute exists in the ophthalmological world in regard to the 
amount of the refractive error which should be neutralized. Some 
surgeons are satisfied only with the so-called "full corrections"; 
others base their corrections upon a definite rule, which requires 
that a given quantity of the refractive defect be allowed to remain 
unneutralized in such cases ; others order the " manifest correction "; 
and still others (and this seems rational) determine the amount of 
the error, which should be corrected according to the patient's occu- 
pation, the apparent needs of the case, and the amplitude of accom- 
modation and convergence. In this connection Dr. Mitchell's views, 
based upon the observation of a great many cases of headache, are 
instructive. He says, " There are sufferers from headache due to 
defective eyes who cannot endure very exact correction without 
increase of pain. There are others who find full relief only when 
the correction is very accurate." We assume that the use of the 
words " exact " and " accurate " used by Dr. Mitchell is equivalent 
to the term " full correction," usually employed by ophthalmic sur- 
geons, and that it is understood, except under certain circumstances, 
that coexisting astigmatism should be completely neutralized. This 
is a just summing up of the case, for it is an undoubted fact that 
some patients with ocular headache find relief only in a full correc- 
tion, although a vast majority (of hypermetropes, at least) are not 
comfortable under such conditions." 

Treatment. — Medicine cannot cure so long as the eyes are used 



DISEASES OF THE NERVOUS SYSTEM. 909 

in reading, writing, or such exercise of vision ; glasses must be pre- 
scribed ; but much can be done to assist rest and glasses by the admin- 
istration of epiphegus, onosmodium, natrum muriaticum, ruta, cimi- 
cifuga, and other remedies recommended in works on the eye. Phen- 
acetin, spigelia, belladonna, and hyoscine are the best palliatives. 

Chloral hydrate causes asthenopia almost invariably, with a pecu- 
liar conjunctional irritation. It ought to be used homeopathically for 
headache from eye-strain, and should cure recent cases, but I find 
no record of its clinical use. 



NERVOUS (NEURASTHENIC) HEADACHE. 

Dr. Day devotes forty-five pages of his great monograph to this 
form of headache. Any full description of its multiform manifesta- 
tions, its symptoms, and the various conditions of the brain which 
cause it, would occupy too much space in a volume of this scope. 
It is in some cases due to an epileptiform neurosis ; in others to an 
abnormal condition of the nerve centres ; in others to " nerve storms " 
which are brought about by mental excitement, mental depression, 
or intense study. It seems to be hereditary in certain families, some 
member of which may have epilepsy, some insanity, and others vis- 
ceral neuroses. It is not so much a disease of the brain, as of the 
whole sympathetic nervous system. At one time the cerebro-spinal 
centres may be affected ; at another the higher psychical centres. 
At times the vomiting centre may be the seat of irritation, the next 
attack may affect the vaso-motor centre. I shall not attempt to give 
the indications for the palliatives, or the radical treatment of this 
protean disease. By some it is believed to be of the same nature as 
hysteria, which defies all apparently indicated medicines. 

I have found that better than drugs is change of place ; any 
change of surroundings, both physical and social, is of more import- 
ance than change of climate. Yet this change may not effect a per- 
manent cure. In a few years another change will become necessary. 
After the climacteric period in both men and women, i. e., after the 
age of forty-five, nervous headaches usually cease. 

A change of diet will often do wonders. Not because of any 
gastric causation, but because there is a change of food. Sufferers 
from cerebral neuroses or neuraesthenia generally eat but little fat; 



910 THE PRACTICE OF MEDICINE. 

they live on vegetables, fine cereals, and a little meat — generally- 
dainty bits like lobster, soft-shell crabs and the like. Often they 
eat a great deal of sugar and various kinds of rich pastry. Now if 
you put such persons on a diet of bacon, fat mutton, butter, olive 
oil, nuts, and only bread enough to go with them, and if you oblige 
them to drink cocoa, or kola chocolate, and eat acid fruits, and 
pearled and granular cereals, you will see a wonderful improvement. 

Each case must be studied ; not only the paroxysm itself, but the 
whole history of the patient and his ancestors, his diathesis, and his 
mode of life. The treatment of his paroxysms has but little to do 
with the radical or constitutional treatment. 

Those long-acting medicines which Hahnemann named antipsor- 
ics are those which we must rely upon as constitutional remedies. 
The palliatives have only a transient action. If the history of the 
patient convinces us that the attacks are epileptiform, the best rem- 
edies are bromide of gold, bromide of strontium, and bromide of 
nickel. These bromides can be continued in suitable doses for years 
without producing acne, mental depression, or any blood cachexia. 
The preparations of silver, zinc, and platina rank next to the bro- 
mides. 

If the vaso-motor centre is chiefly affected, prescribe those medi- 
cines which give them tone and stability. The most appropriate are 
strychnine and its salts, ignatia, nux vomica, brucine, arnica, arsenic, 
nickel, cobalt, iron, zinc, and stannum. 

Some chemical combinations of drugs form our best vaso-motor 
regulators and tonics, namely — arseniate of gold, arseniate of quinine, 
arseniate of iron, arseniate of strychnine, and arseniate of copper. 

The best palliatives in vaso-motor headaches from arterial relax- 
ation are amyl nitrite, glonoine, pauliana, belladonna, hyoscyamus, 
stramonium, agaricus, lachnanthes, selanum, pilocarpine, coffea, 
thea, ether, opium, and alcohol. All these act on the vaso-motor 
centre, dilating the blood-vessels, particularly the capillaries of the 
brain, and when used for this condition should be given in minute 
doses, not stronger than the 3x. 

When the contrary condition, vaso-motor spasm with arterial con- 
traction, is present, the same medicines should be given with physio- 
logical doses. 

Many physicians find it difficult to account for the favorable ac- 



DISEASES OF THE NERVOUS SYSTEM. 911 

tion of those popular compounds of bromides of potassium or sodium 
with caffeine, because it is well known that they are antagonistic. 
The bromides all contract the cerebral vessels, while caffeine in 
moderate doses dilates them. My opinion is that their combined 
action causes a normal equilibrium — one restrains the action of the 
other. This combination certainly acts as a palliative in many cases, 
but never cures. 

Pauliana (or guarana) is a popular palliative in nervous sick-head- 
aches. The powdered bark is given in doses of fifteen to twenty grains, 
in hot water, of the tincture ten to twenty drops every half-hour 
until the pain is relieved. It stimulates the vaso-motor centre, and 
when the face is flushed, the temples throbbing, and the pain in the 
head is violent, will often give prompt relief. Sipping hot or cold 
water also has a stimulating effect on these centres, and many patients 
cure their headaches by this simple measure. 

Morphine is a medicine that will often give magical relief in 
angio-spastic headaches, when the face and extremities are cold, the 
pulse small, slow and feeble ; a hypodermic injection of the one- 
tenth or one-fifth of a grain transports the patient from a hell of 
agony to a heaven of painlessness. But we should reserve this potent 
and dangerous remedy for cases that resist all other remedies. I fre- 
quently use it, out of sympathy, but I never tell my patients the 
true name of the drug. Call it by any other name than morphine. 
Thousands have become morphine victims by the incautious use of 
that drug. In both varieties of nervous headache phenacetin is a 
safe and prompt analgesic. 1 sometimes give five or ten grains at a 
single dose, but it is better perhaps to give the same number of grains 
of the lx trituration every fifteeen or thirty minutes. Antipyrin, 
used in the same manner, will often give relief when phenacetin fails. 
Some recent experiments seem to show that solanine has very potent 
analgesic properties, and is also devoid of the injurious effects of the 
opium alkaloid, but it has not been sufficiently tested. All physicians 
are aware that when the paroxysms of violent pain have somewhat 
abated, there still remains enough to prevent the weary and worn-out 
sufferer from sleeping. It does not require much medicine to cause 
refreshing slumber. One-half a grain of bromide of camphor, ten 
grains of chloral, or chloralamide, ten to twenty drops of passiflora, 
or l-500th of a grain of hydrobromate of hyoscine, will act like 



912 THE PRACTICE OF MEDICINE. 

water of nepenthe. I have seen sleep caused by the lx of scutal- 
laria and cypripedium in the same condition. 



TOXEMIC HEADACHE. 

Definition. — Toxsemic headaches are caused by various poisons 
taken into the system, or formed therein. These poisons are carried 
by the blood to the brain, and cause painful sensations, coma, and 
convulsions. There are several varieties which I shall mention in 
the order of their importance. 

(1) The Headache of Fever. — This is present in the fever of 
catarrh when the frontal sinuses are congested ; the fever of la grippe 
and hay fever ; in the fever of typhoid, and all the eruptive fevers. 
The pain is generally in the forehead and temples ; it is of a dull, 
heavy character, and may be attended with vertigo, flushing of the 
face, and redness of the eyes. In young children it is very severe. 
In cerebro-spinal fever it is generally in the occiput. The poison of 
malarial fever causes headaches chiefly in the frontal region, but it 
may be in the occiput, or on one side only. 

Febrile headaches are caused by an altered quality of the blood 
and elevation of its temperature in the cerebral vessels ; or the pres- 
ence of some specific poison in the blood, and the accumulation in it, 
also, of products of tissue change that are not eliminated by the 
proper channels. Violent and protracted headache in the beginning 
of enteric fever denotes an unusual severe inflammation of Peyer's 
patches and later hemorrhages. 

These headaches are generally alleviated by medicines that reduce 
the temperature and the force of the pulse, namely : aconite, baptisia, 
gelsemium, veratrum viride, phenacetin, belladonna, etc. Phenacetin 
and antipyrin give palliative relief sooner than any other medicinal 
agents. 

The headache of uraemia is due to toxic matters remaining in the 
blood when the kidneys are so diseased that their secreting tissues 
are impaired, and they are no longer able to separate the excremen- 
titious matters from the blood. If the eliminating function is not 
restored, or if they are irreparably injured, drowsiness and stupor 
comes on and the patient dies from uraemic poisoning. Glycosuria 
and Bright's disease generally end in this manner. 



DISEASES OF THE NERVOUS SYSTEM. 913 

When in the course of these diseases severe headache sets in, the 
bowels should be immediately opened by a quick-acting laxative. 
Croton oil and elaterium are often used with good effect. Then if 
the skin remains dry give jaborandi until it causes sweating, or resort 
to the vapor bath. 

Give the patient some quick-acting diuretic, cream of tartar, ten 
to sixty grains in water, taken every hour until it acts upon the bowels 
and kidneys ; or the infusion of digitalis taken at the same time, a 
teaspoonful every hour, when the power of the heart is flagging. If 
stupor or convulsions threaten apply cups to the back of the neck. 
When there is anaemia and anasarca Dr. Day says he has found the 
tincture of perchloride of iron with mercurius corrosivus of great 
service. (One-hundredth grain of the latter and five drops of the 
iron in a teaspoonful of glycerine and water equal parts every four 
hours.) 

If the case is not so urgent we can get good effects from can- 
tharis, turpentine, diuretin, apocynum cannabinum, apium vivus, 
eupatorium purpureum, asclepias cornuti, etc. 

Headaches from carbonic acid and carbon di-oxide poisoning are 
caused by the air of school rooms, lecture rooms, theatres, and court 
rooms, when there is not adequate ventilation. In some of our fash- 
ionable club-houses the rooms are so filled with carbonic acid gas 
and tobacco fumes that many persons cannot remain in them an hour 
without a violent headache, immediately, or the next morning. I 
have had under my care many judges of the criminal courts of 
Chicago. During the winter sessions they suffered much of the time 
with headaches that nearly incapacitated them from work. The 
heart, too, became poisoned and they frequently fainted. There is 
no cure for such cases until their rooms are properly ventilated. 
Alcohol makes matters worse. Marchand's or any good peroxide of 
hydrogen, a teaspoonful in half a glass of water every few hours, is 
the best palliative remedy. 

Arseniate of strychnine 2x, two grains three times a day, will re- 
store the poisoned heart to its normal condition in a short time if 
the patient ceases to expose himself to the atmosphere of crowded 
and close rooms. 

Sewer-gas headache is common in city houses when the plumbing 
and sewerage is defective. The victim of this poison wakes up in 

58 



914 THE PRACTICE OF MEDICINE. 

the morning with occipital or frontal headache. He is stupid, lan- 
guid ; his mouth and throat are dry ; he complains of a feverish 
feeling and has no appetite. No cure is to be expected until the 
drainage is renovated and properly ventilated. This headache is 
often contracted by breathing the gases emanating from street sew- 
ers, privies, and the air of a dissecting-room. 

Dr. Day describes a headache which he says appears to arise from 
" the gas generated by putrefactive faecal fermentation absorbed into 
the blood, thus producing its effects upon the brain and spinal cord. ,y 

His book was written before the discovery of ptomaines in im- 
perfectly digested food and in the faecal contents of the bowels. It 
is now known that the worst forms of headache and neuralgia are 
caused by the absorption of these ptomaines into the blood. It may 
be caused by fermenting food in the stomach, or a faecal accumula- 
tion in the colon. The eructations are acid, acrid, and offensive. 
The colon will be found distended and hard, sometimes throughout 
its whole length. It is useless to give dynamic medicines before the 
stomach is emptied or its contents rendered aseptic. The colon, too, 
must be unloaded thoroughly. Then, to keep up the intestinal and 
gastric asepsis, give peroxide of hydrogen, arsenite of strychnine 2x 
or benzo-napthol (two grains, in chloroform water, every three hours). 
The diet of the patient must be regulated, one grain of papoid with 
five grains of sub-gallate of bismuth given with each meal. 

The headache from malarial poisoning is generally periodic like 
the regular paroxysms of ague. If it occurs every day give quinine, 
cedron, or eupatorium perfoliatum ; if tertian, arsenicum is the rem- 
edy. During the intensity of the paroxysm phenacetin is the best 
palliative. 

The headache of cholaemia can be relieved only by restoring the 
secreting or excreting function of the liver. Euonymin, mercurius, 
chelidonium, chionanthus, and salicylate of soda are indicated. 

The headache of gout and rheumatism require the treatment rec- 
ommended for the two diseases. 

Periosteal Headaches are nearly always syphilitic, and require 
mercury, iodide of potassium, aurum, stillingia, and corydalis. 

Headaches of the Old require barium, zinc, phosphorus, and ergot. 
If the arteries are atheromatus, iodide of sodium, veratrum viride, 
glonoine, and cobalt. 



DISEASES OF THE NERVOUS SYSTEM. 915 

The Headache of Children, when not caused by the toxic air of 
school rooms, is best treated by bromide of camphor, lx to 3x, car- 
bonate of calcium, phosphoric acid, zinc, iodide of ammonium, and 
phosphorus. It is generally caused by early " cramming " in schools, 
before the immature brain can meet the demand upon it. The child 
or young person should be taken from books and study, and made 
to live in the open air and indulge in exercise and amusements. 



CEREBRAL - HEMORRHAGE. 

This is one of the common results of severe active or passive con- 
gestion of the brain, especially if there are miliary aneurisms or ath- 
eroma of the blood-vessels. The results of course are apoplexy and 
paralysis. This is due to the rupture of a blood-vessel, with extrav- 
asation of blood either into the substance of the brain or into its 
ventricles. 

In apoplexy there is loss of consciousness ; in paralysis the mind, 
though impaired, is not suspended in its action. 

The premonitory symptoms of apoplexy are those of cerebral con- 
gestion, to which are added difficulty of speech, partial paralysis of 
one side of the face, defect of sight (due to minute extravasation 
into the retinae), bleeding from the nose, numbness of one side of 
the body ; none of these symptoms need be present, the patient 
being struck down instantaneously with complete coma and insensi- 
bility. This sudden "stroke," however, can occur only when the 
brittle, atheromatous artery bursts, or a large aneurism is ruptured. 

Many of the symptoms which precede apoplexy and paralysis 
also precede thrombosis of the cerebral blood-vessels. For a com- 
plete diagnosis and pathology of apoplexy, paralysis, and thrombosis 
I refer the reader to the works of Hammond, Hart, Baudry, and 
Gowers. 

Treatment. — The treatment of the premonitory symptoms is 
fully given under "congestion." Preceding or during the actual 
attack little can be done. In a few cases I believe I have warded 
off attacks which would have soon occurred, by the bold use of the 
tincture of veratrum viride when there was present very high arterial 
tension. In several cases I have alternated glonoine lc. with the 



916 THE PRACTICE OF MEDICINE. 

veratrum. This may seem strange treatment, but when it is consid- 
ered that the rupture of a blood-vessel is in direct proportion to the 
amount of tension, especially if the vessel is atheromatous, or affected 
with fatty degeneration, the rationale will be apparent. The old prac- 
titioners were aware of this fact and resorted to bleeding to lessen this 
tension, and sometimes, it must be admitted, with decided benefit. 
As before mentioned, both Hammond and Weir Mitchell believe they 
have prevented attacks by the use of thirty grains of the bromide of 
lithium, or bromide of calcium, the action of which is more rapid 
than that of any other bromide. 

During the attach Dr. Hammond declares "the less done the 
better," — he alludes to the purging and bleeding often practiced on 
that occasion. He says there is no more use bleeding for a clot on 
the brain than a clot under the skin. One of his most eminent col- 
leagues of New York City, however, recommends glonoine during 
the attack " to prevent further hemorrhage by opening the arteries, 
and allowing the blood to flow into them instead of out into the brain 
through the rupture," which I consider very good practice. 

Hammond also ridicules the use of iodide of potassium, and prop- 
erly too. There are two remedies, however, which should be given 
during the attack and for some time after, namely : 

Carbonate of ammonium and arnica. The former in small doses 
increases the fluidity of the blood and prevents the formation of hard, 
fibrinous clots. The dose need not exceed one grain every two hours, 
and should be alternated with the tincture of arnica root, ten drops 
in four ounces of water, a teaspoonful every half-hour. 

Arnica certainly possesses the power of hastening the absorption 
of the clot, and it has besides considerable influence in the prevention 
of bleeding from ruptured blood-vessels. It has also many symptoms 
like those preceding apoplectic and paralytic attacks. Dr. Peters 
in his monograph on apoplexy praises it very highly in such cases, 
and gives many instances in which it has prevented second or third 
attacks when taken continuously for weeks and months. 

Baryta stands next in rank in the treatment during the period 
when the clot is being absorbed. It assists in its absorption and the 
removal of the consequences of the pressure. It is suitable to the 
old, feeble, and demented. The bowels should be moved every day 
for awhile after the attack to get rid of the accumulated fseces, or 



DISEASES OF THE NERVOUS SYSTEM. 917 

we shall get ptomaine poisoning of the brain, added to the pressure. If 
an enema will not accomplish it give aloin at night, one-fourth or one- 
half of a grain. The treatment of the resultant paralysis by means of 
electricity, strychnine, or massage, should not be begun until all 
signs of irritation of the brain have disappeared, and the patient 
begins to feel the restraint of confinement, and tries to move the para- 
lyzed limbs, which is soon after the eighth day ; meanwhile we can use 
arnica, nux vomica, or ignatia in small doses (3x) which will allay 
rather than increase the irritability. In fact the judicious use of these 
medicines may, and often does, so favorably affect the paralysis that 
the heroic use of electricity and strychnine is not necessary. If, how- 
ever, the paralysis does not improve during the month after the attack 
strychnine should be given in doses beginning with the one-hundredth 
of a grain (preferably by hypodermic injection), three times a day, 
increasing the dose every five days until decided improvement in 
motion sets in, or until the one-twenty-fifth of a grain is reached. If 
this does not succeed the phosphide of zinc 2x should be used in the 
same manner but by the stomach. I have succeeded by this method 
better than with the large doses recommended by Hammond. 

" The recent advances in brain surgery gives us reason to hope 
for success by operative procedure in those cases in which the clots 
involve the cortex, or in cases of meningeal hemorrhage." (Ham- 
mond.) 

The treatment of meningeal does not differ esseutially from that 
of cerebral hemorrhage, although it would seem that bryonia might 
aid in preventing the meningitis which may follow the hemorrhage. 



TUMORS OF THE BRAIN. 

Little is known of the development of tumors in the brain and 
cord, and generally speaking they develop gradually and unnoticed 
in otherwise healthy persons. Sometimes the symptoms may arise 
soon after a fall, but even then it is a question whether the fall is 
really the cause of a tumor. Most tumors occur in adults, though 
the tubercular infection shows itself generally in children, and strange 
to say, men seem more apt to suffer than women. (Struempell.) 

The various tumors may be distinguished as follows : Glioma, 



918 THE PRACTICE OF MEDICINE. 

sarcoma, syphiloma (gumma), tubercle, carcinoma, psammoma, lip- 
oma, and angioma ; of these gumma and tubercle are the most com- 
mon, then come glioma, sarcoma, carcinoma (usually secondary), in 
the order named. 

General Symptoms. — It must be recognized that symptoms will 
differ according to the location of the swelling, the diagnosis of which 
requires a careful study of cerebral localization, but all tumors exer- 
cise a certain pressure within the cranium which changes the form 
and the character of the circulation and function of the brain, 
demonstrable after death, and detected during life by a few very 
prominent clinical manifestations. 

(1) Headache is one of the earliest and most frequent symp- 
toms, and is as a rule constant, with occasional remissions or exacer- 
bations ; a dull, stupifying wide-spread headache, localized, if at all, 
at the seat of the tumor. A tap on the skull over the proper spot 
may show this seat. (2) Mental hebetude, a changed psychical 
attitude towards the world, characterizes the patient with a brain 
tumor. The expression is stupid, the speech becomes slow, and 
thought difficult, memory fails, and interest slackens ; there may be 
at times loss of consciousness or even apoplexy. (3) Vertigo, a 
slow pulse, and vomiting are the other important symptoms ; sudden 
and intense vertigo must draw attention to the cerebellum ; a slow 
pulse means increased blood-pressure in the brain, and vomiting 
might be called almost essential. This vomiting is not from the 
stomach, but from the brain, and is without nausea, occurring on 
the ingestion of food, and often associated with the vertigo men- 
tioned above. (4) Epileptic attacks do occur, and refer principally 
to involvement of the cortex, especially so if the fits are such as 
to warrant a diagnosis of localized interference only. (5) Optic 
neuritis is another great symptom ; whether it comes from pressure 
and oedema, or from descending neuritis, or from vaso-motor irrita- 
tion, is a matter that concerns the pathologist chiefly ; the interest 
for us lies in the fact that optic neuritis is most always present. 
(The opthalmoscope must be used to establish this condition.) (6) 
Bodily weakness and a tendency to constipation may aid the diag- 
nosis. To repeat, headache, vomiting with vertigo, and optic neuri- 
tis, all at once, will often assure the presence of a brain tumor. The 
discussion of the kind of tumor, and of its localization by means of 



DISEASES OF THE NERVOUS SYSTEM. 919 

more refined symptoms, I must leave to special works on the sub- 
ject. The development is gradual, the prognosis bad, and death 
comes in about a year, unless surgical means (iodide of potassium in 
gummata) can be resorted to. 

Treatment can be only symptomatic. Iodide of potassium and 
mercury can be tried in every case, as syphilis may be present 
unknown to the patient. Otherwise, excision is the only hope. 

Purulent Encephalitis. — I can only mention brain abscess here 
with a caution to suspect it when a few peculiar symptoms are pres- 
ent. As in brain tumor, there are headache and vomiting, but much 
seldomer any optic neuritis. If it runs a slow course, there may be 
no suspicion of the mischief till a sudden fever with brain symptoms 
appears ; but as a rule, encephalitis is acute. It follows scalp or bone 
wounds, a purulent nasal catarrh, any of the infectious fevers, pyae- 
mia, purulent bronchitis, empyaemia, but above all, caries of the tem- 
poral bone and purulent otitis should always engender the fear of a 
subsequent brain abscess. If after a chronic otitis there are sudden 
fever, with headache and vomiting, localized convulsions, a slow pulse 
and symptoms likened to purulent meningitis there can be little doubt 
of the diagnosis. 

Treatment. — The patient may get well, but without an actual 
release of pus by trepanning, no one can tell whether or not it was an 



ACUTE SIMPLE MENINGITIS. 

Definition. — An inflammation of the soft membranes enveloping 
the brain (the dura, pia, and arachnoid). Inflammation may be lim- 
ited to the convexity of the membranes, as in acute idiopathic men- 
ingitis ; or it may attack the base, as in tubercular meningitis ; or 
the dura may be the only membrane indicated, as in pachymeningitis. 

The diagnosis of these different varieties is of considerable diffi- 
culty, but so far as treatment is concerned it does not matter essen- 
tially. The symptoms of acute hyperemia are those of the onset of 
meningitis. There are a few points to which I will call attention. 
(1) That during the progress or even at the onset of acute pericar- 
ditis that disease causes symptoms so closely imitating meningitis 
that it is possible to diagnose only by examining the heart very care- 



920 THE PRACTICE OF MEDICINE. 

fully. In several instances I have been nearly led to diagnose men- 
ingitis, but was prevented by observing closely the pulse and respir- 
ation. On auscultation I discovered a pericarditis. 

Pneumonia sometimes presents symptoms closely similar to men- 
ingitis. In cases of doubt always examine the apex of the lungs. 
If you find crepitant rales and dulness there the delirium is not from 
meningitis. 

Rheumatism sometimes attacks the brain and causes a true men- 
ingitis. There are phases of typhoid fever when the symptoms are 
almost identical with meningitis. The only case of erysipelas I ever 
lost followed the sudden retrocession of the inflammation on the skin^ 
and acute meningitis and death was the result. 

Treatment. — There is nothing in old-school treatment that is 
worthy of our adoption ; the use of ice to the head is cruel and 
unnecessary. The scalp is sometimes frozen by its use, and I believe 
the brain injured. 

Statistics do not show any more recoveries from the use of ice 
than from other methods of treatment. The experiments of Dr. 
Buchan, of West Riding Lunatic Asylum, England, shows that cold 
applied to the head does not reduce the inter-cranial temperature or 
lessen the amount of blood flowing through the brain. Sponging 
the head with cool or warm water and fanning the head cools it just 
as effectually. Some patients are quieted only by the application of 
quite hot water. This is more rational than ice, for moist heat opens 
the external blood-vessels and may relieve the inter-cranial pressure. 

Isolation in a cool, quiet, well-ventilated room is of the greatest 
importance. I allow all the water the patient wants, even if vomit- 
ing occurs, for the vomiting is cerebral and cannot be aggravated by 
drinking. During the inflammatory stage little or no food is needed. 
When effusion sets in the food may be more nourishing. In the 
third stage, even if delirium returns, alcoholic stimulants can be 
given with advantage, for it is a stage of depression. The medicines 
indicated in the first stage are veratrum viride, gelsemium, and aco- 
nite. I need not mention their specific indications, as they are well 
known, but 1 must insist that in order to get prompt results, to 
reduce the inter-cranial blood-pressure and the high temperature, each 
must be given in material doses until we get their physiological 
effects : namely, a reduction of the force of the pulse and heart's 



DISEASES OF THE NERVOUS SYSTEM. 921 

action, and of the temperature. I know that less than one-tenth of 
a drop for an adult will not accomplish this end, and in infants less 
than the one-hundredth will not. 

The dose should be repeated every hour until we see favorable 
symptoms. Not until this result is obtained should we use belladonna* 
agaricus, hyoscyamus, stramonium, or bryonia. Either of these lat- 
ter can be alternated with one of the former, if it is considered best 
to continue them. 

My experience induces me to prefer agaricus or stramonium 3x 
in the majority of cases. They, more fully than the others, meet the 
peculiar delirium. 

When the pulse and temperature has lessened and the stage of 
effusion is approaching, bryonia is the chief remedy. Its action on 
serous membranes is specific. No drug is so homeopathic to the 
inflammation and effusion, no matter where it is located, in the joints r 
peritoneum, pleural membranes, or in the meninges of the brain. (I 
use the 2x.) 

The iodide of potassium equals bryonia, but it should follow the 
latter if the effusion is not prevented or does not show signs of dis- 
appearance. The old school believes this drug to possess decided 
curative powers in this stage. Hammond, Flint, Lyman, and others 
value it highly. Hart does not mention it. Peters instances cases 
of supposed tubercular meningitis cured by large doses, but as this dis- 
ease is considered almost incurable, it is probable that the cases were 
basilar meningitis with effusion. The doses used were ten to thirty 
grains three times a day. 

The cases of poisoning by this drug would seem to show that it 
is homeopathic to this disease, but the indications are not so clear 
as could be desired. The old school bases its curative properties on 
its power of causing absorption of morbid products. I do not deny 
this power in some cases, but I have never seen such results in men- 
ingitis with effusion, yet it should be tried if other remedies fail. 
Especially should it be tried if there is a suspicion or actual knowl- 
edge of the presence of syphilis, or a metastasis of rheumatism. 

Apis mel. has been found especially useful for children, where the 
attack has been sudden, and may have been preceded by erysipelas. 
The symptoms present a good picture of meningitis, with rapid effu- 
sion and very scanty urine. 



922 THE PRACTICE OF MEDICINE. 

Hellebore, so highly praised in all our text-books, seems to me to 
he greatly overrated. I cannot see why it should be recommended 
in the acute stage. Like veratrum album its symptoms point rather 
to the " hydrocephaloid state." I have never seen the slightest bene- 
fit from its use. 

Opium is decidedly useful during the comatose period. It has 
no influence over the effusion or thickening, but it relieves the ve- 
nous stasis and arouses the torpid circulation in the brain. In sev- 
eral cases I have seen surprising effects from morphine. The first 
case, a child of six years, in which I used it had stupor, convulsions, 
incontinence of urine and faeces, dilated pupils, and was pronounced 
incurable by several consultants. Owing to the restless motions of 
the child, its cries and moans, the parents desired the use of mor- 
phine. I had no hopes of the child's recovery. One grain was dis- 
solved in four ounces of water, and of this a teaspoonful given every 
two hours. After two doses the patient slept quietly most of the 
time for twenty-four hours ; partial consciousness returned ; the 
morphine was continued every four and finally every six hours. The 
child recovered after a long convalescence. I believe the recovery 
was due to the morphine. Since that experience I have prescribed 
it on several occasions for the same condition, and have seen several 
apparently hopeless cases recover under it. One grain of the 2x 
(one-hundredth of a grain) is the quantity I have since used. 

In the last stage, when the vital powers are very low, the brain 
paretic with coma, the arms, hands, and feet contracted, arsenite of 
copper has seemed to make the patients more comfortable and aid 
the action of opium. 

Zinc has apparently rescued patients froui impending cerebral 
paralysis. I did not have much success with it until I used the 
phosphide. Several of my correspondents in this country are enthu- 
siastic in its praises. They, like myself, prefer the 6x trituration in 
this condition. 



CEKEBRO - SPINAL MENINGITIS. 

Definition. — A malignant epidemic fever, characterized by pro- 
found disturbance of the central nervous system, ushered in by vio- 
lent vomiting, agonizing occipital headache with delirium, alternat- 



DISEASES OF THE NERVOUS SYSTEM. 923 

ing with somnolence or stupor; an acute painful condition, with 
spasm, sometimes tetanoid, of certain groups of muscles, especially 
the posterior muscles of the neck and those of the back; a general 
hyperesthesia of the surface ; a tendency to rapid disorganization of 
the blood, with petechiae, purpura, or bloody vesicles. The fever 
is irregular with not very high temperature, and generally lowered 
arterial tension. After death there is found engorgement of the 
blood-vessels of the cerebral and spinal meninges, and inflammatory 
exudates beneath them. Although it is said to be epidemic by most 
authorities, sporadic cases do often occur. It is said to be non-conta- 
gious, yet Hirsch, Stokes, and Boudin cite apparent proof that it is 
portable and contagious. I have witnessed three epidemics. One 
in Southern Ohio, one in Michigan, and one in Chicago. I believe 
it is contagious as well as epidemic. I have also seen in Chicago 
and suburbs many sporadic cases. Its specific origin has not yet 
been discovered. It attacks rich and poor, the dirty and the clean, 
those in good health as well as the feeble. Children and young 
persons seem more liable to it than the middle-aged and old. 

There are several varieties. Stille says five ; namely, abortive, 
malignant, nervous, inflammatory, and intermittent. Radcliffe has 
the simple, fulminant, and purpuric. It seems to me that there 
need be but three divisions, viz.: the simple or mild, the malignant 
or purpuric, and the fulminant or collapsing. 

It is rare that high temperatures are seen, and the pulse does not 
denote acute inflammatory action. Yet it is a meningitis, when it is 
not purely congestive. Dr. Bedford Brown says there is a purely 
neuralgic type from which nearly all recover. The death rate is 
very high, varying from sixty to eighty per cent. The diagnosis is 
not difficult even from the first day. The only disease which it sim- 
ulates at its onset is pernicious malarial fever. 

The best and most complete article on this disease, in our school, 
was written by Dr. Arndt for his " System of Practice." It leaves 
nothing to be desired unless it is a more successful treatment, which, 
uncertain as it is, is more successful than that of any other school. 
I shall not criticise the treatment of anyone, but give my own expe- 
rience and the best of both schools. 

Treatment. — The symptoms and pathological changes in this dis- 
ease are so varied that no one drug could produce a disease which 



924 THE PRACTICE OF MEDICINE. 

would be a similimum. Until we find such a remedy or remedies 
we must treat its manifestations as they arise. 

If this disease commences with the symptoms of acute inflamma- 
tion, high temperature, throbbing pulse and arteries, red face, vio- 
lent occipital pain with vomiting, and if we see the patient as soon 
as these symptoms occur, I should hesitate between veratrum viride 
and aconite. If the pulse was hard, bounding, and quick, I would 
prefer veratrum viride, giving it boldly until the force of the heart 
is subdued, and the temperature lowered two or three degrees. This 
may be said to be antipathic ; perhaps so, but I know it modifies 
the disease, and renders it less virulent. The action of the drug 
should not be continued too long or the heart's tonicity will be low- 
ered. I think it is secondarily homeopathic, for in a notable series 
of experiments by H. C. Wood, the reaction from the primal effects 
were great arterial tension, high temperature, and tetanoid spasms. 
Give, of a good tincture, one to five drops every hour. If the patient 
cannot retain it inject it hyperdermatically, mixed with fifteen or 
twenty drops of boiled water. 

Aconite would be preferable if the pulse is small and hard and 
the mental anxiety and physical restlessness very great ; dose, five 
to ten drops of the lx dilution, repeated every hour. 

Belladonna is a valuable remedy if its well-known symptoms are 
present. It acts well after veratrum viride and aconite have modi- 
fied the worst symptoms. 

Solanum and glonoine are recommended. They resemble bella- 
donna, and may be as useful in some cases. In cases which com- 
mence with collapse, like the " sinking chills " of pernicious fever, 
the treatment must be rigorous and immediate. Alcoholic stimu- 
lants are in my opinion utterly worthless. I never saw the slightest 
sustaining or reviving effects from them. Sipping very hot water 
acts better. The patient may be packed in sheets wrung out in hot 
mustard-water very strong, or surrounded in bed with hot bottles. 
But something besides internal and external applied heat is neces- 
sary. 

Some drug that exerts a violent stimulating effect on the heart 
is required, or one that stimulates the heat centre in the medulla ; 
these agents are as antipathic to the condition as is applied heat. 
The strict homeopathic remedy will not in my experience meet the 



DISEASES OF THE NERVOUS SYSTEM. 925 

demands any more than it will in the collapse of pernicious chills. 
When we get the blood to circulating and heat restored to the sur- 
face, then arsenic, veratrum album, veratrum viride, and aconite are 
useful in minute doses. 

Camphor is considered the best stimulant in collapse. But it is 
not primarily homeopathic ; Hahnemann did not think it was, or he 
would not have used and advised drop-doses of a saturated tincture. 
It is not only an arterial but a nerve stimulant when the system is 
overwhelmed by some disease to such an extent as to paralyze the 
reactive powers. In the fulminating form of this disease when the 
•collapse is sudden, camphor should be given in drop-doses (one to 
five) every fifteen minutes till reaction sets in. If this does not 
occur in an hour then the nitrites should be administered. Amyl 
nitrite is too evanescent, though a few whiffs may be inhaled ; but at 
the same time glonoine or nitrite of sodium must be given to pro- 
long the stimulation. One to five drops of the one per cent tinct- 
ure is to be placed on the tongue. In five minutes, if the pulse 
does not get strong, repeat the dose. Its effects lasts from half an 
hour to an hour. Three or five grains of nitrite of sodium act nearly 
as quick but its action lasts two or three hours. Camphor does not 
antidote the effects and the two can be given together. Glonoine 
can be used hypodermatically ; so can the nitrite of sodium, sulphuric 
ether, and brandy. 

Atropine is a cardiac stimulant. When injected into the cellular 
tissue in doses of one-hundredth or one-sixtieth of a grain its effect 
is almost immediate. The heart beats harder and quicker, the face 
and body flush, and the capillary vessels are flooded. When reaction 
occurs and the disease commences its typical course the remedies 
appropriate to each manifestation must be used. 

If the cerebral symptoms are prominent, belladonna, agaricus, 
solanum, hyoscyamus, and cannabis indica are indicated. 

If the cerebro-spinal symptoms are predominant, cicuta, cocculus, 
agaricus, cimicifuga, manaca, and oenantha are useful. The symp- 
toms of each are well known except those of oenantha. The symp- 
toms of this drug collected in " New Remedies " are very similar to 
the cerebro-spinal spasms and convulsions of this disease. The patho- 
logical condition of the brain, medulla, and cord are similar. Besides, 
it causes epileptiform convulsions and trismus. It has been found 



926 THE PRACTICE OF MEDICINE. 

curative in epilepsy and cerebral spasms, and should be tested in this 
fearful disease. The dose need not be below the 3x or above the 6x 
attenuation. In the comatose variety, opium, hyoscyamus, and zinc 
are useful. 

For the tetanic symptoms, nux, ignatia, and strychnine are strictly 
homeopathic in minute doses, while passiflora, calabar bean, and gel- 
semium, in large doses, have been found useful. Many physicians 
claim good success with calabar, especially in the epidemic in Chi- 
cago in 1868. 

Ergot has also been useful according to old-school reports. It 
acts on the brain and cord by contracting the blood-vessels of the 
meninges, when given in doses of thirty to sixty drops of any trust- 
worthy preparation. I used it thus in several cases and am sure it 
aided in the recovery of the patients. 

Dry and wet cupping and the " vacuum " pump applied to the 
spine may draw away the blood from the cord and aid our other 
measures. 

In the purpuric stage, although patients rarely if ever recover, 
crotalus is highly recommended by Dr. Neidhard, who wrote a mon- 
ograph on the poison of that serpent. 

Phosphorus is a favorite remedy for purpura, so are sulphuric 
acid and terebinth, but they are of doubtful utility in this disease, 
because the blood is so badly disintegrated and devitalized. Bap- 
tisia and arsenic may have a good effect in the petchial and low 
typhoid state. 

In a few cases where the heart seemed affected I used cactus with 
undoubted benefit. Recent experiments show that cactus and its 
constituent, cactina, is a powerful cerebro-spinal as well as a heart 
poison. It is a direct irritant to the convulsive centre in the 
medulla. Another species of cactus, anhalonium, is still more pow- 
erful than cactus (cereus), and causes genuine tetanic spasms. 
The following are the indications for cactus : Heavy pains, like a 
weight on the vertex, worse from sounds, even talking; pulsative 
pains in the temples, intolerable at night ; dimness of sight, circles 
of red light before the eyes ; pulsations and buzzing in the ears ; 
contraction in the throat and oesophagus, preventing swallowing; 
oppression on the chest, like a great weight, or as if the chest were 
compressed, with fainting, cold perspiration, and loss of pulse ; sen- 



DISEASES OF THE NERVOUS SYSTEM. 92T 

sation of constriction around the heart, as if an iron band was around 
it ; very acute pain, and such fearful stitches in the heart as to cause 
him to cry aloud, with distressing palpitation, faintness, dyspnoea, 
etc. (Pains everywhere — head, arms, legs, back, chest, heart ; dart- 
ing, springing like chain-lighting, terminating with a sharp, vise-like 
grip, only to commence again a moment afterwards, with restless- 
ness and groaning.) This last symptom is a curative one observed 
by Dr. Lilienthal, and doubtless would be found pathogenetic in a 
full proving. This sense of constriction seems to affect all portions 
of the body. Dr. Farrington writes me that "a very intelligent 
lady, after taking cactus, felt as if her whole body was in a wire cage r 
and that each several wire was being twisted tighter and tighter. 
It causes tonic spasms of the limbs and muscles of the trunk, of a 
twisting character, rotating the body to one side or the other, aggra- 
vated by the slightest touch or jar. 

The favorable effect of passiflora in all tetanic conditions makes 
it worthy a trial in the contractions and tonic convulsions of this 
disease. Its power over insomnia would indicate it, when the vio- 
lent pains and restlessness prevent sleep. It is analgesic as well as 
hynoptic. It probably has a favorable influence over the congested 
circulation in the brain and cord. The dose should be a teaspoon- 
ful of the tincture, repeated every hour or two until some favorable 
effect is observed, or for six hours at least. It is very desirable that 
the active principle of this drug be isolated. 

Chloral hydrate may be useful. Is not very useful for pain. It is 
a pure hypnotic, but there are times when the hyperesthesia, which 
is so intense in this disease, prevents sleep, when no severe pain exists. 
If coffea, cannabis indica, or Scutellaria fail, fifteen or twenty grains 
will give restful sleep of several hours. (Sulfonal or trional are use- 
ful in similar conditions.) 

Phenacetin has the hypnotic action of chloral, though not to the 
same extent, but next to opium it is the most powerful analgesic 
medicine we know of. For the agonizing pain of this fever no other 
remedy is so safe and useful. Instead of giving one large dose, I 
prefer two or three grains every hour. I am not sure but that phe- 
nacetin will prove the best remedy for the real condition present in 
this fever. If it acts only as an analgesic, it places the patient in 
a condition favorable to sleep ; and a great deal will be gained. It 



928 THE PRACTICE OF MEDICINE. 

is not pathologically indicated in meningeal inflammation with effu- 
sion of lympho-purulent exudation, but acts as a sedative to the 
spinal cord. 

Drugs that cause a nearly similar condition should be used in 
this disease in order to test their merits. iEsculus, gymnocladus, 
guaco, oxalic acid, and oenanthe are worthy our consideration. 

The diet and hygiene of this fever may be summed up in a few 
words. The patient must be kept absolutely quiet, owing to the 
extreme hyperesthesia of the nervous system. All visiting, talking, 
or strong lights should be banished, and all noise excluded. In a 
«ity the streets in front of the house should be strown with tan-bark 
or shavings. The room should be well ventilated and its constant 
temperature about 75°. The diet should be milk, butter-milk, kou- 
miss, meat broths, and milk gruels. In most cases alcohol seems 
necessary. In the epidemics of 1865 and '78 some physicians 
throughout the West used pure alcohol in preference to any other 
form. They asserted that the greatest success attended those physi- 
cians who hyper-stimulated their patients with alcohol. It was given 
largely diluted with water, and the amount taken daily was from one 
to four ounces ; the patients were also bathed with alcohol in hot 
water. Per contra, Dr. N. S. Davis, of Chicago, treated all his 
cases without resorting to alcohol, and claimed that his success was 
better than the average. I am in favor of using strong tea, kola- 
chocolate, coffee, and perhaps cocoa, or coca, if the patient can be 
made to drink them. 

The convalescence is often long and tedious, owing to the slow- 
ness of absorption of the lympth and pus thrown out by the menin- 
geal inflammation. So long as this exerts a pressure on the cord, 
so long shall we have contractions, paralysis, and other symptoms of 
irritation. To assist nature in absorbing these products, we must 
use the iodide of potassium, which has acted beneficially. Perhaps 
the iodide or chloride of barium or phosphide of zinc will be better 
adapted to certain cases. Ichthyol possesses powerful resolvent prop- 
erties, and may be of benefit internally in doses of two grains (in 
pills or capsules) three times daily, and at the same time an oint- 
ment of the same, twenty-five per cent in vaseline, rubbed into the 
spine several times a day. 



DISEASES OF THE NERVOUS SYSTEM. 929 

The diet during convalescence should be very nourishing, consist- 
ing of eggs, fat, tender meats, egg-nog, Tokay wine, etc. Children 
who do not take solid food should be fed every three hours with 
Mosquera's beef meal, Chapman's raw-beef blood, Valentine's meat 
juice, and if emaciated, Baker's peptonized beef and cod-liver oil, 
together with the farinaceous and glutenous foods prepared by the 
Health Food Company of New York. Rectal alimentation has to 
be resorted to in some cases, as well as forced feeding by means of 
the stomach pump. 



SPINAL HYPEREMIA (Congestion). 

Definition. — Spinal congestion may be acute or chronic, active 
or passive, as described under cerebral congestion. Unlike spinal 
anaemia, all the symptoms are aggravated by the recumbent posture. 
The pain is dull and aching, similar to that caused by long stooping. 
If the lower portion of the cord is congested, the pain is increased 
by standing. A sudden blow or shock aggravates it. Pressure stead- 
ily applied is not painful. There are disturbances of sensation and 
motion in the extremities below the seat of congestion. Anaesthesia 
or hyperaesthesia may exist. There is always a sensation as if a tight 
cord was bound around the body or limbs. There is partial para- 
plegia, partial loss of expelling power in the bladder, and inconti- 
nence of urine from paralysis of the sphincter. Both conditions may 
exist ; then the urine, collecting in a bladder that is never empty, 
becomes foetid and amoniacal and dribbles away. The rectum is 
similarly affected. The paralysis often extends all over the body. 
It is sometimes difficult to diagnose spinal congestion from spinal 
anaemia, yet there are certain symptoms, like formications, pricking, 
tingling, and anaesthesia, in the former, which are not in the latter. 
I have met with two cases which were caused by lying on the damp 
ground, one from sitting several hours on a cold stone door-step, 
two from excessive muscular exertion, one of which was a child forced 
by its drunken father to walk six miles in a muddy road. The next 
morning the little boy was found to have complete paraplegia, with 
involuntary passage of faeces and urine. 

Treatment. — If it occurs from a sudden chill, a cold rain drench- 



930 THE PRACTICE OF MEDICINE. 

ing the clothing, sitting or lying on cold damp ground, the patient 
should be put in a mustard bath until the external blood-vessels are 
full, then wrapped warm in bed, and rhus tox. given. If reaction 
cannot be fully brought about, give ergot or hydrastis in large doses, 
twenty to thirty drops every three hours. This method cannot be 
called homeopathic, but mechanical or physiological. The action of 
both drugs, when given in such doses, is to contract the blood-vessels 
in the spinal cord. This fact has been established by numerous 
experiments. Hammond and Brown-Sequard consider ergot to be 
indispensable in both acute and chronic cases, and they give abun- 
dant clinical proof of its efficacy. In two cases I had good effecis 
from hydrastis. 

Another physiological remedy is belladonna. It is not generally 
known to our school that while belladonna dilates all the external 
arterioles of the body, it contracts at the same moment those of the 
spinal cord. It has the same action as the hot mustard bath, and 
cannot be primarily homeopathic to spinal congestion. 

I have treated many children with undoubted symptoms of spinal 
hyperaemia where the body was cold. In such cases one or two drops 
of the tincture given every two hours caused no other symptoms than 
those of rapid improvement. In local lumbar congestion a bella- 
donna plaster applied to that region is of great value. The hot 
douche, the water at a temperature of 100°, poured from a height of 
two feet upon the naked back, has been of signal benefit in many 
cases. Chapman's ice bag is a powerful means of contracting the 
vessels of the cord. Great heat and great cold act alike. 

The most useful homeopathic remedies are phosphorus, nux vom- 
ica, and ignatia, which should not be prescribed lower than the 3d. 
I think I cured two cases with strychnine 6th. 

Cannabis indica, rhus, and arnica are useful when the congestion 
has been caused by prolonged, violent exercise. 

iEsculus hippocastanum and glabra are both indicated when the 
congestion is at the lowest portion of the cord. 

Oxalic acid is a special spinal remedy. Its effect is to paralyze 
the vaso-motor, respiratory, and spinal nerve centres. It is a cardiac 
poison, arresting the heart in systole. A study of its pathogenesis 
will show it to be indicated in congestion with paralysis. 



DISEASES OF THE NERVOUS SYSTEM. 931 

SPINAL-ANEMIA. 

(Spinal Irritation, Spinal Neurasthenia.) 

Definition. — A deficiency of blood in the spinal cord, or a 
depraved state of the blood circulating in the cord. Hammond 
teaches that the condition known as spinal irritation is an anaemia 
of the posterior columns of the cord ; while such disorders as reflex 
paralysis, inhibitory paralysis, spinal paresis, paralysis from peripheral 
irritation, are caused by anaemia of the antero-lateral columns. Ham- 
ilton thinks many of the symptoms belonging to both may be caused by 
hypercemia. Both may be right, for passive hyperemia will cause 
about the same symptom as anaemia wherever those conditions are 
located. At first sight it would seem that too little blood in nerve tissue 
would cause absence of pain instead of hyperaesthesia, but the fact is 
that an anaemic nerve is a painful nerve. Someone has said that 
" neuralgia is the cry of a starving nerve." Now a nerve is starving 
when there is not blood enough supplied to it, or when the blood which 
is supplied is loaded with poison, or when the blood flows sluggishly 
through it. Hammond is the great champion of the anaemia-theory, 
and the majority of neurologists are now inclined to his teachings. 

To define spinal irritation, or spinal neuralgia, we can say that 
it is characterized by a hyperaesthetic or morbidly sensitive condition 
of a greater or less portion of the spinal column, and by sentient or 
motor disturbances in one or more of the organs and regions to which 
the nerves proceeding from the affected parts of the spine are dis- 
tributed. 

Tenderness of the vertebrae is the most prominent local symptom. 
This is considered characteristic of anaemia of the posterior column. 
There is a pain in the cord developed by pressure or percussion, 
which should be distinguished from the external tenderness on pres- 
sure. 

The symptoms caused by spinal anaemia in distant parts of the 
body are important, for those painful symptoms are the ones most 
complained of and so often mistaken for local disease. For example : 
when the cervical region of the cord is affected the symptoms are 
vertigo, headache, noises in the ears, disturbances of vision, fullness 
and a sense of constriction around the forehead, and tenderness of 



932 THE PRACTICE OF MEDICINE. 

the scalp. The mind is affected in various ways, from melancholy 
to paroxysms of insanity. Insomnia is common. Neuralgia of the 
head, face, neck, etc. Spasm of the face, twitchings, contraction of 
the neck and arms, paralysis of the arms and hands, aphonia, chorea, 
hiccough, and even nausea and pain in the stomach are protean 
symptoms. 

When the dorsal region is affected the symptoms of the stomach 
are all very prominent. There are also palpitations, oppression of 
the chest, irregular action of the heart, with fainting, dyspnoea, and 
cough, inter-costal neuralgia, pseudo-angina, and infra-mammary 
pain. Paralytic chorea and epilepsy may be present. 

When the lumbar region is affected there are neuralgic pains in 
the lower extremities, the back, and abdomen ; spasm of the neck of 
the bladder, dysuria, or incontinence of urine ; and also pain in the 
uterus, ovaries, testicles, and rectum. There may be either tonic 
contractions or paralysis of the lower extremities ; also clonic spasm, 
simulating chorea. 

I have mentioned these various symptoms for the reason that 
when they are met with in women, especially, and are not removed 
readily by medicines having an affiliation for the organs and tissues 
which seem affected, we should examine the spine for tenderness and 
pain, and if they are evoked, we should direct our remedies to the 
removal of the anaemia of the cord. I doubt not that we lose much 
time and fail to cure many patients because we do not properly diag- 
nose the cause of disease. We may select medicines which seem 
perfectly indicated by their symptoms, but they do not cure because 
they are not homeopathic to the cause of those symptoms. 

Treatment. — When the physician has fully decided that spinal 
ansemia is the cause of the symptoms of his patient, he should first 
remove the cause of the anaemia if possible. Then he should strive 
to improve the quality of the blood, and increase the quantity sup- 
plied to the spinal cord. 

If the patient's environment is bad it should be changed. The 
food should be highly nutritious, the clothing warm and suitable, 
and in some cases good wine, malt liquors and other stimulants 
should be given in moderation. 

In the treatment of spinal irritation it is of the utmost import- 



DISEASES OF THE NERVOUS SYSTEM. 933 

ance that we ascertain if there be any reflex causes of the abnormal 
condition of the circulation in the cord. When we have eliminated 
malaria, impoverished or poisoned blood, we should carefully exam- 
ine the outlets of the body — the uterus, cervix, vagina, urethra, and 
rectum — for constrictions, foreign growths, ulcers, or any local irri- 
tating causes. It is now well known that such outlet-irritations 
cause great aberrations of the capillary circulation in all the organs 
and tissues. They may cause vaso-motor spasm, transient or per- 
sistent, of the peripheral arteries in the spinal cavity ; and until they 
are removed we cannot expect permanent improvement from any 
mode of treatment. The treatment of such local irritation will be 
referred to in another place. The medicines in both schools, i. e., 
with those physicians who make a good diagnosis, are the same. All 
agree that nux vomica, ignatia, arnica, strychnine, brucea, and phos- 
phorus are the principal ones indicated. Now it is a curious fact that 
all these medicines, when given in doses sufficient to be of benefit, 
cause congestion of the spinal cord. The old school claims that 
they act antipathically, or physiologically. What does our school 
say about it? They must either admit that they do act antipath- 
ically or accept my theory, that they are secondarily homeopathic. 
If they must select remedies which are primarily homeopathic they 
must go to other drugs. The one typical primarily homeopathic 
drug for spinal anagmia is ergot, yet no homeopath has ever selected 
it or cured a case with it. I believe that all the drugs mentioned 
above, while they cause congestion of the cord by their primary 
action, induce anagmia or passive hypersemia by their secondary 
action : and, as I have previously mentioned, both the latter condi- 
tions may cause all the symptoms of spinal irritation. The secondary 
effect of a drug is always the opposite of its primary. But we can- 
not cure secondary effects by means of minute doses. We must 
give enough to cause or imitate normal physiological action. We 
cannot cause a normal spinal circulation with strychnine 200th or 
2000th, but we can with the 3d. I do not approve of the large 
pathogenetic doses advised by Hammond and others, but I know we 
must use sufficient medicine to bring about a normal condition and 
no more. Nux vomica and ignatia contain strychnine — the typical 
remedy. Of this the l-25th of a grain is the maximum dose, and 



934 THE PRACTICE OF MEDICINE. 

the 1-1 000th the minimum. The others should be given in the tinct- 
ure or lx dilution — one to ten drops as the case may demand. (Ar- 
nica is useful in the same conditions.) 

I cannot give all the symptoms indicating this group of remedies ; 
that must be left to the physician, but I will give as a general indi- 
cation that they affect the whole cord, and not one particular region. 
Phosphorus, phosphoric acid, the hypophosphites and the phosphides, 
all affect the whole cord, but they affect the sensory and trophic 
more than the motor nerves. Hammond claims the best results 
when he uses the two in combination. One of his favorite mixtures 
is strychnine and phosphoric acid : one grain of the former to one 
ounce of the latter, of which the dose is one to ten drops three times 
a day. Another is phosphide of zinc with nux vomica, one-tenth of 
a grain of the former with one-half of a grain of the extract of the 
latter in a pill, three times daily. I have used these preparations 
for many years, and can confirm his good results. I suspect the 
zinc has but little to do with the cures, unless it acts as a sedative 
to the nerves, for zinc acts on the cord as it does on the brain. It 
causes anaemia therein, and is thus homeopathic. Hammond praises 
the oxide of zinc as a " tonic " in such cases. I have found the 
cyanide of zinc to be more useful. It has great control over those 
neuralgias of the stomach and heart so often met with in spinal irri- 
tation. 

Quinine primarily causes congestion of the cervical region of the 
cord, as well as of the brain, and cures many of the symptoms men- 
tioned as caused by anaemia of that region. A few grains of the lx 
or 2x are quite sufficient for this. 

Cimicifuga is one of our most potent remedies in spinal irritation, 
especially when the lumbar region is most affected. This, too, acts 
primarily as a congestive drug. Cures have been made with doses 
ranging from fifteen drops of the tincture to the lx, or the lx or 3x 
of cimicifugin. (Macrotin.) 

Francesca uniflora (manaca) is a useful remedy next to cimicif- 
uga. It affects the cervical and lumbar cord. When the sufferings 
imitate rheumatism and constant headaches, it cures promptly in small 
doses of the tincture. 

Gymnocladus and cannabis indica should be studied, as both may 
be very useful. The late Dr. Farrington cured a group of symp- 



DISEASES OF THE NERVOUS SYSTEM. 935 

toms with tarantula 200th which may have been due to hysteria. 

Turnera (Damiana) is useful in spinal irritation with passive 
anaemia. " Though slower in action, it is analogous to strychnine in 
effect, cases of poisoning by damiana exhibiting like tetanic convul- 
sions, which are amenable to the same treatment as avails in cases of 
strychnine poisoning. The active principle of damiana, when given in 
therapeutic doses, seems to effect chiefly the spinal and medullary cen- 
tres, not so much as a stimulant to their functional activity as by pro- 
moting the nutrition of the exhausted ganglion cells — inducing the 
tired and irritable cells to assimilate the nutriment offered them. For 
this reason, though slower in action, it is more tonic than strychnine. 
On the bowels, it acts to promote increased peristalsis, causing one 
or two mushy stools per day, and it is an effective remedy in the 
habitual constipation of neurotic subjects, especially those who are 
victims of sexual perversion. Increased diuresis follows its use, and 
many cases of irritable bladder and urethra are very greatly bene- 
fited by it. On the heart, also, it acts as a tonic sedative equal in 
some cases of functional disturbance to cactus grandiflorus. From 
the above resume, it is plain why damiana has proven so efficacious 
in cases of nerve-exhaustion resulting from sexual excesses, and why, 
far from being a direct stimulant of erotic desires, it has been found 
to act as a sedative to abnormal sexual appetite." 

The dose should be graduated from one grain of the extract — or 
one drop of the tincture — to the 3x dilution. 

Hot water and hot bags to the spine have been found useful. So 
are all the forms of electricity. Prolonged rest on the back is advised 
in order to keep the spinal blood-vessels full. Local irritation by 
means of plasters of peppers or mustard give temporary relief, also 
dry-cupping, the flesh brush, and galvanic brush. Dr. Weir Mitch- 
ell's treatment by rest, isolation, and feeding must be resorted to in 
bad cases. 

Bartholow, who has studied the action of gold, says it dilates the 
arteries of the brain, kidneys, and probably all the arterioles. Its 
symptoms show that such must be its effect. It relieves the tension 
of the blood-vessels in the kidneys in dropsy, acting as a diuretic. 
I believe we shall find in gold a most efficient remedy in spinal anae- 
mia, particularly when it is caused by vaso-motor contraction, or any 
local disturbance. A study of its pathogenesis will show many symp- 



936 THE PRACTICE OF MEDICINE. 

toms which belong to anaemia of the cord. Primarily it causes hyper- 
emia of the cord and brain, therefore it should be used in the lower 
triturations. The chloride of gold and sodium is the best prepara- 
tion. Glonoine acts as gold does, but in a more rapid manner. 

Douching the spine with alternate hot and cold water appears to 
have a good influence both in anaemia and hyperaemia of the cord. 
It should be applied morning and evening for several weeks. 

Dr. Elb, of Dresden, considers mikania guaco a remedy for spinal 
irritation due to spinal anaemia or passive hyperaemia. He gives 
minute indications derived from its provings and clinical use. These 
will be found in my " Symptomatology of New Remedies." 



NEURALGIA. 

Definition. — "Neuralgia," says Anstie, "may be defined as a 
disease of the nervous system, manifesting itself by pains, which in 
the great majority of cases are unilateral, and which appear to fol- 
low accurately the course of particular nerves, and ramify sometimes 
into a few, sometimes into all, the terminal branches of those nerves. 
These pains are usually sudden in their onset, and of a darting, stab- 
bing, boring, or burning character. They are at first unattended by 
any local change or any general febrile excitement. They are 
always markedly intermittent — at any rate at first. The intermis- 
sions are sometimes regular and sometimes irregular. The intermis- 
sions are distinguished by complete, or almost complete, freedom 
from suffering, and in recent cases the patient appears to be quite 
well at those times, except that for a short time after which the 
painful nerves remain sore and tender to the touch. In old-stand- 
ing cases, however, persistent tenderness and other signs of local 
mischief are apt to be developed in the tissues around the peripheral 
twigs." 

As to the causes of neuralgia, I believe, with Anstie, that "it is 
universally the case that the condition of the patient at the time of 
the first attack is one of debility, either general or special." There 
may be a delusive mobility and exaltation of the higher nervous sys- 
tem, but that is no sign of real nervous tone. 

In all old, inveterate neuralgias there will be found painful spots 



DISEASES OF THE NERVOUS SYSTEM. 937 

where the affected nerves pass from a deeper to a more superficial 
level, or when they emerge from bony canals. But in the early 
stages they are not present. Pressure may be grateful to the affected 
nerve. Painful spots are equally present in myalgia. In neuralgia 
there is nearly always an instability of the vaso-motor system ; pa- 
tients are liable to sudden changes of vascular tension. At the com- 
mencement of a neuralgic pain there is some arterial tension in the 
part, which may be cold ; but after it has lasted some time, heat 
and a dilatation of the vessels may obtain. 

Neuralgia may be traumatic. It may be caused by direct injury 
to the nerve trunk by external violence, cutting, bruising, the pres- 
sure of a tumor, or ulceration. It may be caused by a shock, as by 
a fall, a railway collision, which gave a jar to the central nervous 
system, or by a severe mental emotion acting on the same part of 
the organism. The fifth cranial nerve is more prone to become neu- 
ralgic from this kind of shock than any other. 

Dr. Anstie divides intra-nervous neuralgias into five divisions. 
(1) Malarious. (2) Those at the period of bodily development. 
(3) Those of the middle period of life. (4) Those of the period of 
bodily decay. (5) Those associated with anaemia and mal-nutrition. 

With the exception of the first and last, these divisions are not 
practical, although Anstie's explanations of their various manifesta- 
tions are very interesting. 

Malaria, as a cause of the most inveterate and distressing neural- 
gias, is well known to all American physicians, and their cure some- 
times cannot be accomplished except by a radical change of climate. 

Anaemia and mal-nutrition are conditions that may be present at 
all periods of life, from infancy to old age. I believe they cause 
four-fifths of all neuralgias, outside of those of malarial origin. 

Closely allied to anaemia and mal-nutrition, and often a cause of 
those conditions, is a condition of the blood designated toxaemia. 
This condition is induced by the entrance into the blood of mineral 
or vegetable poisons, such as mercury and arsenic, or nicotine, caf- 
feine, morphine, etc., or the poisons generated in the human body,, 
or in the bodies of animals, the meat of which is eaten by the human 
race. They are called ptomaines, and many of them are violent 
poisons to the nervous system, closely simulating in their action the 
most virulent mineral and vegetable poisons. 



938 THE PRACTICE OF MEDICINE. 

Of late much attention has been called to these toxic products, 
as a cause of inveterate neuralgias. They are generally formed in 
the contents of the alimentary canal, but often in the liver, spleen, 
and kidneys. 

General Treatment. — Before considering the local varieties of 
neuralgia, I shall discuss the treatment of the three general divisions, 
malarial, anaemic, and toxaemic. 

Malarial Neuralgia, particularly the acute, must be treated ac- 
cording to the directions laid down under " Intermittent Fever." As 
I mentioned in that article, it will assume almost innumerable forms, 
imitating all the local varieties, and even various local neuroses and 
inflammations. 

If the patient has been exposed to malaria or lives in a malarious 
region we may safely treat his neuralgia as malarious, especially if 
the attacks are periodical, no matter what nerve or organ may be 
affected. The chief remedies are cinchona, quinine, arsenic, cedron, 
gelsemium, natrum muriaticum, alstonia, eucalyptus, and sulphur, but 
in chronic cases, nothing but a removal, temporary or final, to a non- 
malarial region will permanently cure. Usually one or two seasons, 
L e., one or two summers spent in the mountains, or in a northern 
climate where malaria is not known, will confer immunity from 
future attacks. 

Neuralgias from Anmmia must be treated mainly by hygiene, and 
good blood-making food. The surroundings of the patient must be 
healthy ; his or her residence must be in such a condition as to sup- 
ply pure air and pure water. The food should be highly nitrogenous. 
" Pain," says Romberg, " is the prayer of a nerve for healthy food." 
If the anaemia is from malaria, follow the directions above ; pure air 
will soon remove it. If from syphilis, the iodides of potassium and 
mercury will cure it. Stylingia syl. is also a remedy of great value 
in syphilitic cases. (See Keyes' experimenting on their blood-mak- 
ing power.) If from cholaemia, make the liver eliminate bile pig- 
ment from the blood. If from absolute loss of blood by hemorrhage, 
give china and the mineral acids. If good food is not proper ljr 
digested give nux vomica, strychnine, helonias, hydrastis with pep- 
sin, papayotin, papoid, or pancreatin. Add some preparation of iron 
to enable hemaglobin to be made from assimilated food. 

Good digestible meats and meat broths should be the staple food. 



DISEASES OF THE NERVOUS SYSTEM. 939 

Some farinaceous food, as gluten bread made from cereals, should be 
added. Fruits should be eaten in moderation. Instead of iron in 
officinal form, those spring waters which contain iron in combination 
with alkaline salts, with sulphur or arsenic, are preferable; the 
Columbia spring of Saratoga ; the Chalybeate spring at White 
Sulphur, Va.; the Excelsior iron spring of Missouri ; the iron springs 
at Hot Springs, N. C; thePyrmont spring in Westphalia, or the Put- 
nam spring in New York ; the Anderson and Chalybeate springs at 
Bedford, Pa.; and the many iron springs in Illinois, Wisconsin, Col- 
orado, Utah, and California, are suitable ; but the patient should not 
visit iron springs unless they are in a healthy region. 

If toxaemia is the cause of the neuralgia, our aims should be to 
see that all the excretory functions be made to act normally. The 
skin should be kept clean and active. The stomach made to digest 
food normally. The bowels should be kept active, in order that all 
waste products are carried off as soon as formed, and that no portion 
of the digested food containing toxic products in the intestinal canal 
be absorbed. At one time it was claimed that purgatives would cure 
nearly all cases of anaemia. By anaemia was meant impoverished 
blood from mal-nutrition. Such treatment was very successful for 
no other reason than that the waste of the food was carried out of 
the body before the ptomaines and leucomaines were absorbed. We 
need not use purgatives, but we should keep the bowels open every 
day by suitable food and simple laxative medicines. 

The local varieties of neuralgia may be divided into (1) Super- 
ficial ; (2) Visceral. 

Superficial Neuralgias are subdivided as follows : (a) Neuralgias 
of the fifth nerve, namely, supra orbital, palpebral, nasal, occular, 
and trachlial ; (b) cervico-occipital ; (c) cervico-brachial ; (d) inter- 
costal ; (e) lumbo-abdominal ; (f) crural ; (g) sciatic. 

Treatment. — There are some medicines, like arsenic, that seem 
to be useful in all neuralgias. Others which seem adapted to cer- 
tain local manifestations. 

Arsenic and quinine may be useful in all the above if they have 
a malarial origin and occur periodically. 

Belladonna (or atropine) and aconite are particularly useful in 
neuralgias of the fifth pair of nerves. The former when there is 
arterial fullness, throbbing, with red flushed face, twitching in the 



940 THE PRACTICE OF MEDICINE. 

parts affected, blood-shot eyes, delirium, shooting pains, dimness of 
vision, photophobia, full pulse, and coldness of the feet. If bella- 
donna is given, the 3d or 6th will often act magically ; if atropine, 
the 6th trituration is applicable. 

Aconite is almost specific in trifacial or trigeminal neuralgia 
when the pain is agonizing, with great anxiety, restlessness, and the 
patient is almost frantic with the pain. The face may be red or 
pale, but the pulse is generally quick, hard, and small. 

Aconitine (crystalized) is considered by many greatly superior 
to the tincture in the treatment of violent congestive neuralgias. It 
is a powerful poison and must be given with caution. Begin with 
a grain of the 3x (one-thousandth of a grain), which can be repeated 
every hour. Aconitine is now prepared in granules of the 1 -500th 
and l-250th of a grain. One of these can be given three or four 
times a day. If the patient complains of numbness and tingling in 
the face and hands, with relief from pain, the medicines should be 
suspended. 

Spigelia is equally useful if the left side of the face and the left 
eye is the seat of the pain. The pain is often located principally in the 
eye-ball, and the upper lid droops and twitches ; even if both eyes are 
affected it is still the remedy. Sometimes the heart is at the same 
time affected with stitching pain and violent palpitation. Trigemi- 
nal neuralgia is sometimes called migraine or true " sick headache." 
It is so named because it generally ends with vomiting, not because 
it originated in the stomach, for the vomiting is a reflex symptom. 

If aconite, belladonna, or spigelia fail to cure, we have in sepia, 
sanguinaria, and pulsatilla excellent remedies if their symptoms cor- 
respond with those of the attack. 

But migraine is often very intractable, and the above medicines 
will all fail. We are sometimes forced to use palliatives, even if we 
desire to give the true similimum during the interval between the 
attacks. 

A new group of palliatives has lately been introduced — the chem- 
ical synthetic drugs so popular at the present time. Among the 
most important are phenacetin, antipyrin, acetanelid, exalgin, etc. 

I have tried them all. They are uncertain, and some dangerous 
or unsafe in their action. 

Phenacetin is the safest and most valuable, and I do not hesitate 



DISEASES OF THE NERVOUS SYSTEM. 941 

to use it in violent, acute cases. Having no provings, it must be 
used empirically. The dose ranges from five or ten grains of the 
lx to five or ten grains of the crude drug. No two patients require 
the same dose. Begin with the smallest, and if no alleviation is 
obtained in an hour, double the dose. The maximum dose is twenty 
grains, but this quantity will rarely be required, and it is not best to 
increase it. The only unpleasant symptom I ever saw from this 
drug was profuse sweating. 

Antipyrin in smaller doses, not exceeding ten grains, is useful 
when belladonna, though indicated, does not relieve. 

Antifibrin (acetanelid) in doses not to exceed five grains, some- 
times acts happily. Exalgin has been highly praised, but I never 
obtained good effects from it. It is an uncertain drug, and in small 
doses, one-fourth or one-half of a grain, has often given rise to un- 
pleasant symptoms. 

Some varieties of migraine are called " angio-spastic " because the 
arteries in the parts affected appear to be constricted, and at the 
same time the face and head are cold and pale. Relief is obtained 
as soon as the blood returns to the closed vessels. Aconite, veratrum 
album, or arsenic are homeopathic to this condition, and often give 
quick relief, but not always. We are then obliged to use antipathic 
or physiological remedies — those that will relax the vaso-motor spasm. 
Alcohol will do this ; a glass of champagne or whisky is often effect- 
ual ; but nitrite of amyl, glonoine, or any other nitrite, acts more 
quickly. Homeopathically they are useful in just opposite conditions. 
Dr. Hering first recommended glonoine in headache due to vaso- 
motor paralysis when the temporal and other arteries and capillaries 
are full almost to bursting, but when thus indicated the 3d is the 
proper dose. 

In chronic migraine we cannot expect to cure unless we give the 
appropriate remedy for months during the intervals between the 
attacks. I have cured a few cases with sulphate of nickel, giving 
one-tenth of a grain three times a day. Others have been cured by 
the bromide of gold or the chloride of gold and sodium, in doses of 
one-sixtieth and one-hundredth of a grain three times a day. In a 
few cases I found these doses caused some pathogenetic symptoms, 
but a good cure was made. In very sensitive patients the 3d tritu- 
ration or even the 6th will cure. I rarely use the bromides of potas- 



942 THE PRACTICE OF MEDICINE, 

sium or sodium except in cases of acute congestive neuralgia, when 
they sometimes give immediate relief, or when great nervousness and 
sleeplessness follow an attack. A single dose of twenty grains is suf- 
ficient for this purpose. 

Caffeine is a favorite remedy with some practitioners. A cup of 
strong coffee (which contains a grain probably) will often relieve a 
case of migraine. I have had very good results from two-grain 
doses of the lx of the citrate when the patients did not drink coffee* 

A very popular preparation is a combination of caffeine with 
bromide of sodium or potassium. The use of it has been abused, 
and has become a habit with many women who resort to it when 
even threatened with pain in the head or sleeplessness. Its use should 
not be encouraged, as it prevents us from making permanent cures 
with other and appropriate medicines. It is as injurious to some 
persons as the habitual use of alcohol or opium. 

Acute neuritis is often mistaken for neuralgia of the fifth pair* 
I remember one notable case in a man of fifty. The first few days 
the pain seemed purely neuralgic. It affected the right temporal 
region, the eye, and region of the eyebrow. Neither aconite nor bel- 
ladonna arrested it. Then an erysipelatous swelling and great heat 
of the parts appeared, followed in a few days by a herpetic eruption 
on the affected parts, and on the eyelids and eyeball. There were 
several pustules on the cornea. Rhus and mezereum were prescribed, 
but did not prevent injury to the lower lid, which became everted ; 
but thanks to the skill of the late Dr. "Woodyatt the sight was not 
permanently injured. One of the most intractable cases of facial 
neuralgia I ever treated was cured promptly in a very heroic man- 
ner, after lasting several weeks and defying all apparently indicated 
remedies. I called my father, an old physician, to see the case — a 
woman of forty or fifty. After hearing the history he observed that 
the tongue had a dirty brown coat, the breath was offensive, and the 
skin slightly jaundiced. He suggested ten grains of calomel. It 
was given and caused purgation with immediate disappearance of 
the pain, which did not return. This case was probably caused by 
cholaemic poisoning. Since then I have cured several cases in the 
same manner. 

There are other remedies which are useful in this kind of neu- 
ralgia. Chelidonium has cured many when the pain appeared about 



DISEASES OF THE NERVOUS SYSTEM. 943 

noon every day. Iris versicolor, carduus mar., chionanthus, and 
euonymin are often indicated. Salicylate of sodium is a powerful 
hepatic as well as a rheumatic remedy. Gelsemium has an elective 
affinity for the lower maxillary branch of the trigeminus, especially 
if the paroxysms are periodical. The dose of gelsemium should be 
carefully selected. I have found in some cases that no impression 
was made on the pain until enough was taken to cause slight dim- 
ness of vision and heaviness of the eyelids. In most patients a drop 
or two of a good fresh-root tincture, repeated every hour, will cause 
those symptoms. 

One of our indigenous plants, the passiflora incarnata, is gaining v 
an empirical reputation for the cure of neuralgia. It grows in the 
Southern States, and has had a local celebrity for nearly fifty years 
for curing tetanus in men, women, children, and horses. It is suc- 
cessful in obstinate insomnia. Many cases of neuralgia have been 
promptly cured by it. A recent writer says : " In pure neuralgia 
its effects, in five or ten-drop doses of the tincture are often won- 
derful. Two cases will illustrate this : A working-man had suf- 
fered from neuralgia for a week, and his face was almost raw from 
the external applications made to effect relief. Two five-drop doses 
of the tincture relieved the pain inside of half an hour, and there was 
no return. The cure was complete. 

" Another case was of a woman who had suffered from neuralgia 
for three months, and had been under professional treatment during 
that time, but with no relief. Passiflora, in ten-drop doses, relieved 
and cured in a remarkably short time. In the liquor and morphine 
habit, passiflora, in half-teaspoonful doses, has done wonders. Let 
patients abstain from the liquor or morphine as long as they can. 
When the desire becomes irresistible, then take the passiflora, and 
the effect will be to soothe the nerves and induce, often, a sweet and 
refreshing sleep." 

We have no provings of this plant, and its exact position in our 
materia medica is yet uncertain. No pathogenetic symptoms have 
been observed from its use, even when large doses have been given. 

A rare form of prosopalgia is called by Trousseau, tic epilepti- 
form. This is a most intractable malady, and in a majority of cases 
no cure can be effected except by surgery. The affected nerve can 
be stretched, or a portion taken out, resulting sometimes in a cure, 



944 THE PRACTICE OF MEDICINE. 

or temporary relief. I have treated six cases, not one of which was 
cured — two had the nerve stretched and in one a portion of the nerve 
was extirpated. No medicines gave even temporary relief except 
morphine and atropine by hypodermic injection. I did not try 
aconitine hypodermically, but its use in other hands has not been 
successful. If used, only l-500th of a grain should be injected. 
Theine has been suggested. A brief item in a recent medical jour- 
nal stated that hyoscine had cured a case even after nerve section 
failed. The reporter's name was not given. 



CERVICO-OCCIPITAL NEURALGIA. 

This, as its name indicates, occupies chiefly the region of the neck 
and occiput, but often extends to the parietal region, the face and 
even the arms. It may cause irritation of the cervical and sub-max- 
illary glands. 

Paget and Anstie consider this form the most amenable to treat- 
ment. Blisters to the back of the neck, painting with iodine or the 
application of the electric brush, often cure it. It is often mistaken 
for myalgia, "stiff neck," and acute rheumatism. Hypodermic 
injections of chloroform (five drops), carbolic acid (ten drops of the 
twenty per cent), theine (one-half of a grain), or atropia (l-200th 
of a grain), all have cured. I have cured several cases with cannabis 
indica lx, ten drops every two hours ; rhus tox lx, piper methis- 
ticum, and one case with an ointment of aconitine, one grain to an 
ounce of vaseline. 

CERVICO BRACHIAL. 

This group includes all the neuralgias which occur in nerves orig- 
inating from the brachial-plexus or from the posterior branches of 
the four lower cervical nerves. The most important characteristic 
of the neuralgias of the upper extremity is the frequency with which 
they invade several of the nerves derived from the lower cervical 
pairs. It affects the shoulder, arm, forearm, and hand, and is often 
very troublesome and severe. 

Anstie says that in his experience the most common seat of this 
neuralgia is in the ulnar nerve. 

My experience is that, in the majority of the cases I have treated, 



DISEASES OF THE NERVOUS SYSTEM. 945 

the seat of pain has been in the shoulder, in the cutaneous branches 
of the circumflex. Neuralgia of the musculo-spinal and radial, near 
the wrist is often met with, but I have rarely seen it. 

Putzel says that brachial neuralgia is rarely periodic ; the parox- 
ysms appear irregularly, and oftener than other varieties. He men- 
tions as a striking characteristic that the " pains dart both up and 
down the nerves in the majority of cases instead of toward the per- 
iphery, as they usually do in other cases." 

There is commonly a stiffness of the muscles, sometimes so severe 
as to lead to considerable contraction. Some of my patients com- 
plained of drawings and cramps in the muscles of the arm ; also of 
formication, numbness, and a painful sensitiveness to the touch. 

Weir Mitchell (" Diseases and Injuries of the Nerves ") mentions 
many trophic changes, such as atrophy, " glossy skin," as if the in- 
tegument was polished and drawn tightly over the fingers, palms, and 
back of the hand. 

Brachial neuralgia resembles sciatica in its etiology. The ma- 
jority of cases are due to local causes, which may be situated in the 
spinal column, in the course of the nerves, or at their peripheral 
distribution. It is often a symptom of chronic cervical pachymen- 
ingitis. I have treated two cases which were supposed at first to be 
brachial neuralgia, but proved to have a spinal origin. They ended 
in partial motor paralysis of the arm, contracture, and muscular 
atrophy. 

In the beginning of the disease it is often mistaken for acute 
myalgia or rheumatism following exposure to cold, damp air, but its 
real character is soon evident. 

Treatment. — Entire rest of the arm must be insisted on. The 
arm should be carried in a sling or bound to the side. Even when 
apparently cured, manual exercise will bring on a relapse. 

Many authors assert that medicinal treatment is of no avail. 
They rely altogether on hypodermic injection of morphine and atro- 
pine. 

Lilienthal recommends aconite, arnica, arsenic, ferrum, graphitis, 
ignatia, lycopodium, phosphorus, rhus, sepia, staphisagria, sulphur, 
turpentine, and veratrum, but he gives no special indications, and 
on consulting their pathogeneses I find no symptom of a definite 
character. 

60 



946 THE PRACTICE OF MEDICINE. 

In my cases I tried them all with no perceptible effect, except 
aconite, of which I gave internally, and applied the tincture exter- 
nally. 

Hempel mentions a case in which the pain in the deltoid region 
was cured by large doses of aconite, but he gives no proof that it was 
a brachial neuralgia. 

Phytolacca seemed to benefit one case when the pain was in the 
right arm and followed the ulnar nerve. 

My two worst cases were not benefitted by electricity, or massage 
carefully applied. 

Professor May, of Philadelphia, reported several cases benefitted 
by theine, one-fourth to one grain, injected into the region of the 
affected nerve, but in three cases where I tried it, it gave only tem- 
porary relief. In two cases I injected seven and one-half grains of 
antipyrin with no benefit. 

INTER - COSTAL NEURALGIA. 

Definition. — One of the most frequent as well as mildest forms 
of neuralgia. The pain is strictly confined to the course of the 
nerves, generally the anterior branches, and the paroxysms differ in 
no respect from those of other varieties. 

If the pain is severe the patient leans toward the affected side 
(usually the left), and is afraid to take a long breath. The parox- 
ysm may be excited by coughing, sneezing, or any sudden movement. 

The pain is usually felt on the left side, from the sixth to the 
ninth intercostal spaces. In one variety the mamma is the seat of 
the pain, generally in women, although men are sometimes the vic- 
tims. This is " Cooper's irritable breast." The pain darts through 
the breast in every direction, and the mamma, as well as the integu- 
ment of the chest, becomes highly hyperaesthetic, so that the slightest 
touch of the clothing is unendurable. At the same time firm pres- 
sure as from a bandage produces decided relief. This in time gives 
way to anaesthesia over the surface supplied by the nerves. It is 
liable to be confounded with myalgia, or pleurodynia, as it is some- 
times called. It may be mistaken for pleurisy by those ignorant of 
the nature and diagnosis of that disease. Herpes zoster, or " shin- 
gles," is the only complication of any importance. 

Patients often call me to treat what they suppose to be pleurisy, 



DISEASES OF THE NERVOUS SYSTEM. 947 

alleging that they have had it several times before, and that it was 
treated as such by their physicians. On investigating the symptoms, 
however, I found it easy to decide that their attacks were neuralgic. 
So severe sometimes is this pain that the patient is seized with ana 
inexpressible and deadly feeling of cardiac oppression, very similar 
to an attack of angina pectoris. In such patients there is generally 
a degeneration of the arteries, and probably the coronary vessels. 

Symptoms similar to inter-costal neuralgia often occur in girls 
and neurotic women, and are due to reflex irritation from the uterus 
or ovaries. The pain is usually infra-mammary, nearly always just 
below the left breast. It may also occur during pregnancy or when 
nursing, if the nipples are diseased. Aortic aneurism of the descend- 
ing arch, or abdominal portion, may cause it, or it may arise from 
disease of the vertebrae. 

Anaemia is often a radical cause of this affection. Finally it may 
be purely hysterical, for we know that hysteria will imitate nearly 
all disorders. During the last few years a large proportion of cases 
of inter-costal painful affections have been caused by the poison of 
la grippe. 

Treatment. — First, be sure the pain does not arise from myalgia 
or acute rheumatism ; or that it is not caused by commencing Pott's 
disease, or spondylitis deformans. 

Then ascertain if possible the cause. If anaemia prescribe arsen- 
iate of iron. The best form of this drug is found in the " Levigo 
Water," from a spring in Tyrol. The dose is one teaspoonful in 
half a glass of water, after meals. If from leucorrhoea, remove it by 
appropriate remedies, which will be found to include in their symp- 
toms both disorders (cimicifuga, kali carb., sepia, and calc. hypo- 
phos.). If from prolonged lactation the child should be weaned, and 
the mother given phosphoric acid, cinchona, helonias, cimicifuga, 
hydrastis, or arseniate of iron. 

Our standard homeopathic remedies for pleurodynia are : 

Arnica when the pain resembles pleurisy; the integuments of 
the affected side is sore and feels bruised, the patient cannot lie on 
that side long, and must change position often. If the pain has its 
origin in a blow it is fully indicated. An arnica plaster applied 
over the most sensitive region often gives relief and acts as a stay to 
the parts. 



948 THE PRACTICE OF MEDICINE. 

Sticta pulmonaria is of special importance in cases resembling 
pleurisy not of traumatic origin. 

Borax is recommended by Lilienthal, but theoretically, I suppose, 
as I know of no verifying clinical experience. 

Spigelia has many symptoms which make it indicated. I have 
found it useful when the pain occurs in connection with chronic 
endocarditis. 

Guiacum has been useful in that form of pleurodynia which 
occurs during the softening of tubercles in the lungs, also in cases 
purely rheumatic. 

Rananculus presents a most perfect picture of this disease, but 
I have not had good success with it. It may be because I did not 
use it in large enough doses. Some of its symptoms point to that 
rare disease, neuralgia of the diaphragm, as it causes a violent spas- 
modic hiccough. I generally used the third dilution. Perhaps the 
tincture would be better. 

Rhododendron seems indicated when, with the pain, there is " dys- 
pnoea from a sensation of constriction of the chest," a symptom 
often observed when herpes is impending. When herpes zoster 
appears during the pain, mezereum is thoroughly indicated. 

An ointment of oil of peppermint in vaseline (equal parts) gives 
great relief to the pain when rubbed gently into the skin over the 
eruption. 

Senega is useful when there is a cough, with a sensation of raw- 
ness of the bronchial mucous membrane, with pleurodynic pains. 

The tincture of persea (alligator pear) has lately been recom- 
mended for inter-costal neuralgia. It is given internally in small 
doses and rubbed on the affected parts. It is used for this purpose 
in the West Indies and Central America. 

Antipyrin, said to be very effectual in doses of three to five grains 
every four hours, has been known to give decided relief when the 
pain is paroxysmal and spasmodic. 

Phenacetin has been very useful in my hands when the inter-cos- 
tal suffering is intense, and the patient begs for some palliative ; 
especially is it useful when the cause is grippe. Many of the most 
violent cases I ever treated originated in an attack of that myste- 
rious disease. It may require ten, twenty, or thirty grains, given 
in doses of five grains every hour, before relief is gained, but when 



DISEASES OF THE NERVOUS SYSTEM. 949 

gained the patient sleeps calmly. I have seen no unpleasant results 
from such doses. The only pathogenetic symptoms I ever observed 
from its use were palpitation (in one case), and profuse sweating 
in several. It is much safer than antipyrin or exalgin, although I 
cured a case with the latter in a young woman, with two-grain doses 
of the lx repeated every hour for twelve hours. 

The physician will often be tempted in violent cases to use hypo- 
dermic injections of morphine, but it should be remembered that 
injections into the chest walls are apt to cause alarming symptoms 
of heart failure. It is not the drug injected that causes the collapse 
and syncope, but the act of injecting, for the syncope comes on imme- 
diately, before the drug could possibly act. I know this to be a fact, 
for in two cases I injected a few drops of tepid water and the result 
was just the same. 

LUMBAR NEURALGIA. 

Definition. — A neuralgic affection, arising from the lumbar 
plexus. It does not at the same time involve all the branches of 
the plexus, but is limited to one or two. The branch most gener- 
ally affected is the crural, then next in frequency the ileo-inguinal 
and ileo-hypogastric. Whichever branch is affected, at the height 
of the paroxysm the pain often radiates to other branches. There 
is often intense hyperesthesia over the track of the nerve. 

In neuralgia of the ileo-inguinal the pain darts into the scrotum 
or labia majora, and is often attended with frequent and painful 
micturition. 

In crural neuralgia the pain is felt in the distribution of the 
middle and internal cutaneous nerves to the anterior and inner as- 
pects of the thigh, and sometimes down the inner part of the leg to 
the foot and great toe. Herpes may, but as a matter of fact rarely 
does, attend it. This is the variety so often present during attacks 
of dysmenorrhea. It also complicates ovarian neuralgia, and I have 
known two cases when it followed a forceps delivery. It is some- 
times combined with neuralgia of the testes, a horribly painful 
affection. 

Lumbar neuralgia should not be mistaken for lumbar myalgia^ 
or "lumbago" as it is sometimes called. It is doubtful if the lum- 
bar muscles are actually affected by true rheumatism. In lumbar 



950 THE PRACTICE OF MEDICINE. 

myalgia the attack is often sudden, when turning over quickly in 
bed, or when making some lifting or twisting effort. Lumbar neu- 
ralgia is slower in its access. The former will not allow the patient 
to move without pain. The latter does not affect movement to any 
great extent. Eising from a seat is very painful in lumbago, not 
generally so in neuralgia. Both may, however, be combined. 

I can find no mention of the confusion of this form of neuralgia 
with passage of calculi through the ureter, but in a case which was 
under my care for two years, the man suffered from very violent 
paroxysms exactly similar to those attending neuralgia of the ileo- 
inguinal and crural branches. The pain in one testicle and the dys- 
uria were excruciating. No remedy selected by the symptoms was 
of any benefit. The urine was carefully examined from time to time 
without finding any traces of mucus or calculus. One day in his 
office he had a sudden desire to urinate, and during the act felt 
something pass down the urethra, causing violent cutting pain. It 
dropped into the urinal and was fortunately saved. It proved to be 
a calculus composed of prisms of cystine, a very rare form of stone. 
It was as large as a small white bean, very spiny and irregular. No 
pain was ever felt afterwards. 

Treatment. — Examine for uterine or ovarian disease, and if found 
treat it. If not, examine the urine for traces of calculus. If the 
urine contains uric acid in excess, give lithia in some form or boro- 
citrate of magnesia. If the crural nerve is affected and is worse 
during menstruation, give xanthoxyllum or cubebs. If the ovary is 
sensitive, give conium, valerianate of zinc, or bromide of ammonium. 
If the pain starts from the lumbar region or seems to be complicated 
with myalgia, give cannabis indica, five drops of the tincture or lx 
every hour, or cimicifuga in the same doses. In a very obstinate 
case, in a young woman, the pain extending over the course of the 
ileo-inguinal and crural, which resisted cannabis, phenacetin, and 
codeine, immediate relief followed the injection, hypodermatically, 
into the inner side of the thigh of seven grains of antipyrin. I once 
cured a case by placing two belladonna plasters on the lumbar re- 
gion, one on each side of the spine. 

Putzel says, " Small fly-blisters applied over the painful spots at 
the exit of the affected nerve from the lumbar spine, are of decided 
advantage." Also, " In my own hands the greatest amount of relief 



DISEASES OF THE NERVOUS SYSTEM. 951 

has been obtained from the use of strychnine, beginning in doses of 
l-48th of a grain three times a day, and gradually increasing until 
physiological effects are obtained." 

Kaue recommends for crural neuralgia, phytolacca and staphis- 
agria, but I cannot imagine why, for not a single symptom of the 
crural nerve is to be found in their pathogeneses. 

Coffea seems indicated and should be tried if the intense erithism 
of that drug is present, and the patient does not use coffee. 



SCIATICA. 

Definition. — A disease which ranks next to trigeminal neuralgia 
in interest and importance. It is characterized by the occurrence of 
pain in the course of the sciatic nerve and its branches. It may be 
restricted to the gluteal region and upper part of the thigh, or may 
extend to the sole of the foot or toes. The principal painful points 
are those which correspond to the sacral foramina, where the large 
and small sciatic nerves emerge from the pelvis ; a series correspond- 
ing to the branches through the fascia, a fibular point at the head of 
the fibula, an external malleolar, and an internal malleolar. 

Sciatica generally begins with a dull heavy ache which gradually 
becomes more and more intense, and which, like all the other forms of 
neuralgia, is aggravated by muscular exertion. It is subject to exac- 
erbation of violence, during which the least agitation of the body still 
further increases the intensity of the suffering. The pain sometimes 
darts like electric shocks through the whole length of the nerve. It 
may occur suddenly, like the case mentioned by Putzel, which came 
on immediately after rising from a kneeling posture. The pain may 
shoot from the origin to the periphery of the nerve, or vice versa, or 
shoot up and down, with terrific violence. The agony may be so 
great as to tempt the patient to suicide. The pain may be con- 
fined to the main trunk or be limited to one of the branches. It 
was formerly believed and taught that sciatica was caused by rheum- 
atism, gout, or syphilis, but recent authorities like Hammond, An- 
stie, Putzel, and others deny any such general causes. It seems to 
be hereditary. I have met with many cases where the tendency to 
the malady could be traced back for several generations. 



952 



THE PRACTICE OF MEDICINE. 



It is rarely if ever caused by malaria, although the malarial cach- 
exia aggravates it exceedingly. There is often great hyperesthesia, 
the slightest touch of a sheet or hand causing intense pain and spas- 
modic twitching of the limb. Convulsive contractions of single mus- 
cles, as of the calf and back of the thigh may occur, and sometimes 
the whole leg may be convulsed, contracted, or twisted. In my own 
case I frequently felt at night a rotary drawing of the muscles, turn- 
ing the knee inward, occurring after the violence of the pain had 
subsided. 

Hammond implies that sciatica is a neuritis, but Pritchard 
( u Amer. Jour. Med. Sciences," Jan., 1891) says a careful distinc- 
tion must be made between sciatic neuritis and sciatic neuralgia. He 
gives the following table : 

Sciatic Neuralgia. 
Same, but anaemia and malaria oftener. 
Pain sharp and more constant; pares- 
thesia (except numbness) rare. 



Sciatic Neuritis. 
Causes: Wounds and tumors. 
Pain duller, in paroxysms, and in the 

intervals paresthesia, as pricking, 

tingling, and numbness. 
Movement, especially forced extension, 

gives pain. 
Anaesthesia, often rapid in onset, and in 

limited areas. 
There may be swelling of the nerve 

trunk, and tenderness on pressure. 
Trophic changes in the skin, hair, nails, 

and muscles, with paresis or paralysis 

and reaction of degeneration. Faulty 

position of body. (Babinski.) 



Pain not affected by movement. 

Actural anaesthesia very rare, but gen- 
eral numbness may occur. 

No swelling, and distinct pain (not ten- 
derness) on pressure at certain points. 



None except wasting from disuse. 

Quite exceptional. 

Sciatica may be caused by passive congestion of any of the pel- 
vic viscera, by retro-version of the uterus, displaced ovaries, hemor- 
rhoids, fissure of the anus, pregnancy, intra-pelvic tumors, exudations 
in the broad ligament, hardened faeces in the rectum, excessive abuse 
of sexual passion or enforced abstinence. Sciatica is frequently mis- 
taken for myalgia, but the pain of myalgia is always absent if the 
limb is kept quiet ; sciatica is present when the leg is motionless as 
well as during movement. Locomotor-ataxia is with difficulty dis- 
tinguished from sciatica. Hip-joint disease may be the cause of 
symptoms believed to be due to sciatica. 

Treatment. — After treating and removing uterine, ovarian, syph- 
ilitic, and hysterical causes, if any, ascertain if there is constipation. 



DISEASES OF THE NERVOUS SYSTEM. 953 

I have found this to be a common cause, and I can understand why- 
purgatives have always been held in such high esteem in the treat- 
ment ; in my early practice, when I considered it heretical to use 
them, I treated unsuccessfully several cases with the remedies rec- 
ommended in our text-books. A copy of Braithwaite's " Retrospect " 
came into my hands, in which was narrated a cure by means of cro- 
ton oil, so extraordinary that I determined to throw aside my preju- 
dices and try it. Selecting the worst case, a man nearly bedridden, 
and a great sufferer with sciatic neuralgia, I gave him one drop of 
croton oil. Imagine my astonishment when he came into my office 
the next day, and performed some gymnastic feats such as he had 
not been able to do for years. He said that after three or four hours 
he had six or eight very profuse watery stools, mixed with hard 
lumps of faecal matter, the quantity of which greatly surprised him. 
After the evacuations he was relieved of nearly all the pain, and slept 
soundly all night, which he had not done for months, except under 
the use of opiates. He had no return of the sciatica afterwards, but 
I enjoined him to keep the bowels open by means of fruits and mild 
laxatives. Since that time I have cured several intractable cases by 
croton oil, or elaterium, which acts nearly in the same manner.. 
These hydrogogue cathartics act in two ways. They remove old 
accumulations of faecal matter which have become impacted in such 
a situation as to press upon the nerves. They also cause an exos- 
mosis from the congested pelvic tissues and veins, and relieve the 
stasis by the free flow of serous fluid. I have often cured a recent 
sciatic neuralgia with one large dose of Epsom salts, or Rubinat, or 
any of the " bitter waters." 

Where there seems to be only an accumulation of faeces in the 
rectum and colon, a copious enema of hot water with glycerine is 
sufficient. This should be repeated until the bowel is thoroughly 
unloaded. A pill of aloin and hyoscyamus or aloin alone (one-fourth 
of a grain), by carrying off impacted faeces, will cure many recent 
cases of sciatica. 

When the pain during the paroxysm is unendurable we are 
obliged by the entreaties of the patient to use some immediate pal- 
liative agent. Morphine, or morphine and atropine, hypodermic ally, 
is generally resorted to, and there is no objection to its occasional 
use, but it should not be repeated often for fear of the patient con- 



$54 THE PRACTICE OF MEDICINE. 

tracting the morphine habit. I have used injections of codiene, one- 
half of a grain, with much benefit. The agent used in the syringe 
should be changed occasionally. I have found warm- water injections 
to give as much relief as morphine in some cases, if the patient be- 
lieved it was morphine. 

Deep injections of chloroform, ether, and cold water have been 
credited with the cure of many cases. 

The chief remedies used in our school are arsenic, rhus, bella- 
donna, cimicifuga, colocynth, cocculus, gnaphalium, iodide of potas- 
sium, ledum, menyanthes, nux vomica, phytolacca, ruta, stillingea, 
and zinc. 

Arsenic and rhus should be compared, as they resemble each 
other in many of their symptoms. 

Belladonna presents a very good picture of sciatica, and is prob- 
ably used more than any other medicine. It is especially useful if 
neuritis is present, and the course of the nerve can be marked out 
by the cord-like swelling and redness. 

Cocculus and colocynth compare well ; both have the motor 
symptoms, the cramps, convulsive drawings, etc., which is found in 
some cases. iEgedi's cure, by colocynth, of an old case of sciatica 
with its spasms and violent pains, is one of the marvels of our ther- 
apeutics. The dose was the 3d dilution. 

Not long ago I found narrated some notable cures of sciatica 
with purgative doses of colocynth. The reporter supposed the cures 
were brought about by ridding the bowels of impacted faeces, but 
the main symptom of his cases were those belonging to colocynth 
provings. 

Gnaphalium has cured some severe sciatic pains, when the whole 
trunk and main branches were affected. 

Ledum has quite an array of sciatic pains, but they are mixed 
with rheumatic. 

Lilienthal (" Therapeutics ") mixes, in all his indications for 
remedies in sciatica, many myalgic symptoms. In fact, they are 
about equal, and the indications are as good for one disease as for 
the other. It is the same in practice. Both diseases are often found 
in the same patient at the same time. Iodide of potassium, phyto- 
lacca, and stillingia are excellent medicines in syphilitic cases. But 
I have rarely met with true syphilitic sciatica, and then there was 



DISEASES OF THE NERVOUS SYSTEM. 955 

coincident motor ataxia. I well remember one case in which I used 
all the approved medicines and iodide of potassium, in all doses from 
one to ten grains, four times a day, without effecting a cure. The 
patient then placed himself under the care of a notorious specialist, 
who cured him with massive doses of iodide of potassa. I was told 
by the patient that he swallowed during the two months he was under 
treatment the enormous quantity of half an ounce a day, nearly all 
the time. But he was cured. 

When sciatica is the result of neuritis, and nearly all chronic 
cases are, the treatment will be protracted and perplexing. The 
medicine should be carefully selected and continued for weeks. 
Arsenic has cured some of the worst cases on record, but the patients 
were under its influence for months. The dose was from one to ten 
drops of Fowler's solution three times daily. 

The difference in action between arsenic and iodide of potassium 
is, that the former acts on the axis cylinder or nerve itself, while 
iodide of potassium acts on the fibrous sheath of the nerve. 

Now in inflammation of the sheath, usually called neuritis, there 
is effusion, just as in synovitis. 

Iodide of potassium causes absorption of the effused fluids. When 
both nerve and sheath are involved, the iodide of arsenic would 
better meet the indications. Phytolacca and cimicifuga act like 
iodide of potassium ; both are indicated in neuritis, but cimicifuga 
does not cause effusion. If the inflammation is clearly rheumatic, 
aconite and veratrum viride internally and topically are indicated, 
while bryonia is a good remedy in the first stage. Hypodermic 
injections of aconitine into close contact with the nerve has made 
some brilliant cures. Begin with the l-500th of a grain. It can 
be increased to the 1-6 Oth, and one obstinate case required the 
l-20th, but it is hardly safe to go beyond the 1-1 00th of a grain. 
An ointment of aconitine or veratrine, five to ten grains to the ounce 
of vaseline, often gives great relief in neuritis and intense sciatic 
pain. 

Turpentine is a very old remedy for sciatica. It has cured when 
given in immense doses. In several cases on record half an ounce 
was given, but while it cured the sciatica it caused a cystitis and 
injured the kidneys. Usually I have found two to five drops, three 
or four times a day, sufficient. I believe it to be indicated partic- 



956 THE PRACTICE OF MEDICINE. 

ularly when the cause of the sciatica arises from some irritation of 
the urinary organs. 

Dr. C. L. Dana reports good success in rheumatic patients with 
sciatic pains from equal parts (four drops of each) of turpentine and 
gaultheria. 

Salol has made some excellent cures. Dr. Aschenbach used it on 
himself ; after being confined to his bed three weeks, and trying 
numerous other drugs, he was immediately cured by seven grains in 
the evening and fifteen at midnight. 

Phenacetin is perhaps the most popular remedy with the regu- 
lar school, and they certainly make surprising cures of sciatica 
with it. They use it in five-grain doses, repeated every hour or two, 
until the pain disappears. I can verify its value, both in five-grain 
doses and less, having cured many cases with five-grain doses of the 
Ix trituration. 

Antipyrin is equally popular with some physicians, and in the 
same doses as phenacetin, but we cannot always be sure it will not 
cause alarming symptoms in patients susceptible to it, even in very 
small doses. The same can be said of acetanelid and exalgin ; they 
should not be used except as a last resort, and then very cautiously. 

Among the external applications none has given more brilliant 
results than congelation. A spray of ice water, or ether, often 
relieves the pain in a few moments. A spray of chloride of methyl 
has been used with wonderfully good effect. Dr. Devonis (" Revue 
Medicale," Aug. 16, 1884) congealed the integument over the nerve, 
and says " the effect was marvellous." The relief from pain was 
instantaneous, though there were sometimes slight relapses, which 
yielded at once, however, to a repetition of the congelation. The 
skin was blanched temporarily, and only occasionally was vesication 
produced. Since Devoris' experience Dr. Raymond announced to 
the Societie de Biologie that he has obtained similar favorable results 
from the same method. He found, however, that the results were 
just as favorable if he used the spray on the unaffected leg, and not 
necessarily along the course of the affected nerve. He thinks this 
proves that the relief from pain was due to an impression made upon 
the spinal centres by refrigeration of the peripheral nerve termina- 
tions rather than by any influence upon the nerve itself. Dr. Ham- 



DISEASES OF THE NERVOUS SYSTEM. 957 

mond prefers ice bags applied to the posterior part of the thigh. Sir 
Joseph Fayer relates an interesting case of chronic sciatica, probably 
a neuritis, in a man. The pain was very severe and continuous, with 
violent paroxysms. The patient was wasted and worn ; the posterior 
muscles of the thigh were atropied. On examining the limb he dis- 
covered some fluctuation, with fulness and tenderness in the course 
of the sciatic nerve near its origin in the upper part of the limb. He 
introduced a long narrow knife into the swelling until it entered the 
sheath of the nerve. This gave exit to a couple of drachms of clear 
serous fluid, which was followed by immediate relief of suffering, and 
rapidly resulted in complete recovery. This should lead us to exam- 
ine the limb carefully in severe cases. 

Dr. Menz, of Yidalia, La., reports a brilliant cure by means of a 
deep hypodermic injection of twenty drops of a four per cent solu- 
tion of cocaine over the sciatic foramen, in a case of sciatica of ten 
years' duration. The pain ceased immediately, and six weeks after 
there had been no return of the pain. 

Nerve-stretching has cured a few obstinate cases of sciatica. For 
the details of the operation see recent works on surgery. 

The mistletoe (viscum album) has been accredited with the cure 
of some severe cases. (See " New Remedies," Vol. 2.) 

Viscum is a close analogue of ergot, being used for the same pur- 
pose. In an old number of Braithwaite there is a report of several cases 
of sciatica of long standing cured by one-drachm doses of ergot (fluid 
extract). According to present physiological teachings ergot is sup- 
posed to cure neuralgia due to congestion of the nerve, such as we 
And in some cases of neuralgia of the trigeminus. Such large doses 
could cure only by contracting the dilated vessels which supply the 
diseased nerve, as it is not primarily homeopathic to any true nerve 
pain. Ustilago ought to act equally well. Dioscorea has cured sci- 
atic pain radiating from the abdomen ; aesculus, when it was caused 
by hemorrhoids ; zinc, when occurring in connection with spinal irri- 
tation. I have made many excellent cures with valerianate of zinc, 
in doses of one grain three times a day. (Always give it in pills or 
granules, on account of its villainous smell.) 

Caffeine, gauranine (paullinia), and theine have cured cases of 
sciatica when taken internally or used hypodermically. Theine was 



958 THE PRACTICE OF MEDICINE. 

introduced by Professor Mays, of Philadelphia, who has reported sev- 
eral cases cured promptly by injecting, near the most painful portion 
of the nerve, the one-eighth, one-half, and one grain of pure theine. 
He insists that theine acts differently from caffeine, and should be 
made from good tea. We know that caffeine and theine, while sim- 
ilar, are not identical, as chemists assert. 

Nux vomica has cured many cases of sciatica. It should be a 
good remedy on account of its specific action on the spinal cord. I 
believe it cures for this reason, and not because it has any special 
affinity for the sciatic nerve. It appears to act best when the func- 
tions of the cord are below normal, as in anaemia of the cord. I have 
had better success, however, with its alkaloid, strychnine, given for 
a long period, in doses of one-hundredth of a grain. Putzel says it 
has given him better satisfaction than any other drug. "In idiopathic 
cases, and those due to exposure, etc.," he begins with one forty-eighth 
or one thirty-second of a grain three times a day, and gradually in- 
creases the dose until physiological effects are produced. I doubt if 
this extreme use of strychnine is ever necessary. 

Those who have read Hilton on " Rest and Pain " will remember 
how earnestly he pleads for absolute rest in some diseases of the 
nerves. I have found that in some cases of sciatica absolute rest 
seemed all that was needed to effect a cure. Hammond emphatic- 
ally declares that it is invaluable, and advises that we should not 
merely order the patient not to walk about or confine him to his bed, 
but that we should put the leg in a splint. He uses the old-fash- 
oned long splint reaching from the axilla to the sole of the foot, and 
attached to the body and lower leg by means of a bandage. Dr. S. 
Weir Mitchell uses the same method. Both claim excellent results. 



NEURITIS (Inflammation of the Nerve). 

Neuritis may be acute or chronic, local or general ; that is, affect* 
ing one nerve or several, or all the motor nerves of the body. As 
an acute neuritis is most always followed by the chronic condition, 
and as the local form differs somewhat from the multiple, I shall 
discuss neuritis in two sections : localized neuritis and multiple neu- 
ritis. 



DISEASES OF THE NERVOUS SYSTEM. 959 



LOCALIZED NEURITIS. 

Etiology, — Cold is a frequent cause (rheumatic neuritis)* 
Trauma, such as wounds, blows, pressure, the result of fractures and 
dislocation, and hypodermic injections ; Syphilis, sympathetic exten- 
sion, and tumors. 

Pathology. — An isolated neuritis is generally adventitial ; when 
the fibres themselves are affected there is a parenchymatous con- 
dition. In the acute stage there is swelling and redness, or even 
small hemorrhages into the nerve tissue. If this is limited to the 
sheath it is a perineuritis ; if into the nerve itself, an interstitial neu- 
ritis. These changes may be continuous or local. The fibres may 
be a sclerosis of the nerve ; or if fat is finally deposited, there is the 
lipomatous variety (Ley den). When due to syphilis a neuritis may 
have the character that marks other syphilitic formations. 

Symptoms. — There may be some constitutional disturbance, espe- 
cially if cold is the cause. The chief symptoms are local, and pain 
is essential, in the nerve, and often in its distributions. The nerve 
is sensitive to pressure ; pain is increased by movement, and is burn- 
ing, boring, worse at night ; if the nerve can be reached (as in the 
brachial or ulnar) it will be found enlarged, and occasionally the 
skin is red with slight oedema, and some hyperesthesia ; the muscles 
become weak, but their powerlessness is due rather to increase of pain 
than to paralysis. Perspiration may be profuse, and at times erup- 
tions on the skin occur. As the acute inflammation subsides, the 
local pain disappears, leaving a general numbness, with tingling, 
formication, paresthesia, and weakness. Tactile sensation is impaired 
and loss of power is marked ; ultimately when there is not recovery 
the muscles atrophy, contractures occur in the fingers, or toes, and 
the nails and skin suffer from defective nutrition (glossy skin). 

The electrical changes vary according to the involvement of each 
nerve. They may be absent, or perfectly typical as in facial paraly- 
sis, which is a neuritis. 

Course and Duration. — An acute neuritis may last only a few 
weeks and disappear entirely, or run into the chronic form, and per- 
sist for months ; or if the course (as a dislocation or tumor) be not 
removed, a cure is impossible. 

Diagnosis. — A sharp distinction must be drawn between neuri- 



960 THE PRACTICE OF MEDICINE. 

tis and neuralgia, though many mistakes are made in calling a 
neuritis neuralgia. In neuritis there is inflammation. The nerve 
trunk in its whole length is sore, or in one spot only. There is ting- 
ling or anaesthesia in the distribution of the nerve, with some degree 
of paralysis, and not rarely trophic changes, and intermission is due 
only to improvement or to opiates. In neuralgia, on the other hand, 
distinct remission is the rule. There are spots, where the nerve 
approaches the surfaces, which are decidedly painful, whereas the 
rest of the nerve may not be at all sensitive ; it may even feel relieved 
by pressure. There is no inflammation, no paralysis, and is cured 
not so much by local treatment as by attention to the general condi- 
tion of the individual. 

Treatment. — Remove the cause, be it local, as a wound, or general, 
as gout or syphilis. Absolute rest is necessary ; all contractions in 
the limbs must be prevented, and the posture should be such as to 
discourage secondary contractions. The limb may be steamed to 
induce diaphoresis, and then surrounded by hot poultices. Cold may 
be used to advantage if an injury is the cause. It must always be 
remembered that too prolonged applications of either heat or cold are 
dangerous, as the nerves controlling the trophic conditions of the skin 
are in this case themselves involved. If the pain demands relief, the 
best measure, and one far preferable to morphine, is the hypodermic 
injection of cocaine into the affected area, about one-fourth to one 
grain ; it acts locally, and even has an effect on the inflammatory pro- 
cess itself. In the rheumatic form, the salicylates and antipyrin are 
useful, and mercury in small, repeated doses has an unmistakable 
influence for good. In the chronic stage, counter-irritation is useful, 
and electricity here can be employed (whereas it is distinctly harmful 
in the acute stage). Apply the constant current in a mild form. In 
very old cases it may be wise to cause actual pain with the current, 
and to resort to the induced current to stimulate the contracting mus- 
cles. Massage must be persevered in and the general health most 
carefully attended to. Arsenicum, apis mel., arnica, and hypericum 
are remedies of great value in either the acute or chronic form. 

MULTIPLE NEURITIS (Polyneuritis). 
Multiple neuritis implies a neuritis in which many nerves are 
inflamed at once or rapidly in succession. This is the most notice- 



DISEASES OF THE NERVOUS SYSTEM. 961 

able symptom. Besides, it is symmetrical, even when only a few 
nerves are involved on both sides. The condition in question is 
rather parenchymatous than adventitial, and most often it is due to 
a morbid blood-poison, either organic or inorganic. To illustrate the 
difference between multiple and simple (parenchymatous and adven- 
titial neuritis) the influence of gout may be used ; gout causes a sim- 
ple neuritis by a deposit in the nerve sheath or connective tissue that 
some exciting influence starts into inflammation. If the blood itself, 
while carrying the poison of gout, should thereby become irritative 
and attack the nerves there would be a multiple neuritis. Gowers 
accordingly groups the disease and its causes as follows : 

1. Toxic : (a) Metallic, as lead, arsenic, etc. (b) Non-metallic, 
as alcohol, the most frequent cause, and diabetes, as in this case 
some substance allied to sugar must be present in the blood. 

2. Toxaemic, due to some virus in the blood : (a) Primary, in 
which the neuritis is part of the first effect of a virus either (i) 
derived from without the body, as the neuritis of leprosy and other 
forms not yet definitely understood, or (S) produced within the body, 
as may be septicaemia neuritis, (b) Secondary, in which the toxae- 
mic agent at first causes some definite disease, followed at a variable 
interval by a polyneuritis, as that of diphtheria, smallpox, variola, 
typhoid, tubercle, and perhaps syphilis. 

3. Endemic, due to local organisms, having this for their primary 
or secondary effect, as malaria and beri-beri. Strictly these belong 
to class 2 (a) (i). 

4. Rheumatic, following exposure to cold, and is possibly a morbid 
blood state. These probably belong to class 2 (a) (^). 

5. Cachectic and senile forms, in which degeneration of the nerves 
seems part of a general mal-nutrition. 

I cannot go further into the pathology of the disease, and shall 
now give the symptoms of a general, acute multiple neuritis, leaving 
for a slightly more detailed paragraph the discussion of alcoholic neu- 
ritis, lead and arsenic poisoning, and beri-beri. It is worth mentioning 
here, however, that syphilitic neuritis bears a marked resemblance to 
the phenomena in Tabes ; it has even been called pseudo-tabes (neuro- 
tabes) and as Tabes (q. v.) is most always a post-syphilitic affection 
it is more than probable that the two states are pathologically allied. 

Symjrtoms. — There are three classes of symptoms, one or the 



962 THE PRACTICE OF MEDICINE. 

other of which usually predominates : motor weakness, sensory dis- 
turbance, and incoordination. The type of the motor weakness is 
the wrist drop and steppage gait. The sensory symptoms are ting- 
ling, pains, and tenderness. The incoordination is the same as in 
early locomotor ataxy, and is often associated with loss of muscular 
sense. The onset varies according to the cause, but as one or the 
other of the above types predominates, the attention is attracted to 
the relative objective signs. Often there is a premonition fever, 
with bronchitis (after catching cold). The temperature rises to 103° 
or 104°, there is general malaise, the body aches, but pain in the nerves 
is by no means always complained of. Distinct symptoms appear 
only when the patient complains of tingling in the fingers and toes 
with vaso-motor disturbances of the extremities or cramps. Then 
comes loss of motor power, in the legs first as a rule, giving finally 
a picture of ascending paralysis ; then foot and wrist drop, then a 
general loss of power, a flabby paralysis, often extreme, so that the 
diaphragm may be the only muscle capable of respiratory power. 
The muscles waste and may be hyperaesthetic, with soreness and stiff- 
ness in the limbs. Landry's paralysis can at times hardly be dis- 
tinguished from it. Loss of coordination usually accompanies the 
loss of power ; it is difficult for the patient to balance himself or to 
perform fine movements with his fingers. Tremors (in alcoholic 
cases) is often conspicuous before loss of power. Electrical reac- 
tions are those typical of nerve lesions. The knee-jerk and other 
muscle reflexes are always lost, but the sphincters seldom lose their 
contractility, and the skin reflexes disappear only in extreme cases. 

Trophic changes occur in prolonged cases, and they then are sim- 
ilar to those of ordinary neuritis, such as glossy skin, stiff joints, 
changes in the nails, hair, etc.; oedema of the legs is common. 

The course is variable. The patient may die within ten days, 
through paralysis of respiration or of the heart ; but in a case of 
moderate severity the disease may persist for five or six weeks, 
remain stationary for a time, and then get well, though the paralysis 
and contractures may linger for months ; even then a good recovery 
is not improbable. The first sign of improvement is a diminution of 
pain and hyperesthesia, though muscle tenderness is slower to cease. 
When tingling that had once appeared and disappeared, reappears, 
it is a sign of improvement. 



DISEASES OF THE NERVOUS SYSTEM. 963 

Diagnosis is important, as the treatment, by attacking the cause, , 
can do much to help the patient. This, especially true of alco- 
holic neuritis, applies to all forms. The motor and sensory symp- 
toms, in their unvarying symmetry, must be carefully observed. Pain 
on deep pressure strengthens the suspicion, especially when com- 
bined with tingling either before or contemporaneous with motor 
weakness. Tabes can be excluded by lack of lightning pains and 
pupillary reaction. Again, excluding tabes, no disease gives pain 
and a paralysis with loss of muscle reflexes (knee-jerk), except mul- 
tiple neuritis ; hysteria has never yet produced an actual wrist-drop 
or a loss of knee-jerk. A girdle-pain means involvement of the cord ; 
neuralgia is never symmetrically bilateral, and always has " painful 
points." 

Treatment. — Suggestions as to special treatment of the various 
forms will be given as they are discussed, but here a general survey 
only of the treatment to be adopted in every case can be given. In 
all cases the cause should be discovered and removed if possible. 
Rest is essential ; rest in bed, with confinement of affected limbs if 
thought necessary ; warm fomentations over the affected nerves sooth 
the inflammation and comfort the patient, but caution must be ob- 
served to prevent troublesome trophic disturbances. If the patient 
can stand it, daily warm baths are of value. The feet and arms 
must be suitably supported by splints or bandages, to prevent the 
deformities apt to arise from paralysis of the extensors, or from the 
habitual flexure of the knees. 

Drugs seldom have a marked influence on the morbid process. 
The post hoc propter hoc reasoning must be avoided here as else- 
where, lest too great attention be paid to dosing and too little to 
hygiene. In the acute febrile stage more symptomatic treatment 
must be followed, to preserve intact the functions of secretion and 
excretion and to support the patient's strength. In rheumatic cases 
the salicylates do good, special attention being given to the kidneys. 
Gout must always be suspected, and if found (in alcoholics), treated. 
After the febrile stage a somewhat more direct treatment may be 
adopted with strychnine, iron, and quinine. Arsenic in small doses 
(always with the fear of increasing the trouble) is useful, and gen- 
eral tonics. Cocaine in doses of one-half to one-fourth of a grain 
helps a stomach depressed from alcohol. 



964 THE PRACTICE OF MEDICINE. 

If anodynes are unavoidable, cocaine and codeine are better than 
morphine ; in fact, opium should never be used, as in any neuritis a 
habit is easily acquired. 

Antipyrin, acetanelid, cannabis indica, bromides, sulphonal, chlo- 
ralmid, hyoscine, all have their sphere, and may be used at discretion. 
Electricity, using only the galvanic current with large sponge elec- 
trodes, is especially serviceable in the stationary and convalescent 
stage, but must never be pushed to the point of pain. It can be ap- 
plied daily, and then it helps materially to maintain the nutrition of 
the muscles. The nerves themselves are not, as a rule, affected one 
way or the other, though slight sensory loss is sometimes overcome 
by the faradic brush. 

After the febrile stage, nerve vibration is a remedy that promises 
well for the relief of pain, and also for the restoration of normal 
motor function and coordination. The treatment should be given 
with the same regularity and frequency as in all this general class of 
cases ; but the time for holding the hammer over individual points 
is governed by the rule for neuralgias, so far as the relief of pain is 
to be obtained. The operator should place hammer at farthest per- 
ipheral point of each of the nerves affected, following the same se- 
quence at each sitting. He should also in these cases apply the flat 
disk over the region of solar plexus and over the nerve roots on each 
side of the spinal column. 

Massage and passive motion should be persevered in, and mean- 
while the limbs can be bound carefully in cotton or wool. Gowers 
warns against any temptation to perform tenotomy. 

ALCOHOLIC NEURITIS. 
This is without doubt the most important form of multiple neu- 
ritis, being as common as all other forms put together. It occurs 
more in steady tipplers, " soakers," than in drunkards or those who 
go on sprees, and for that reason is found of tener among women than 
men, as women drink more in secret. The actual amount of alcohol 
taken has little to do with it, as the general health and such factors 
as gout, rheumatism, and syphilis modify the effects very much. 
The onset is gradual (seldom with fever) and is usually first marked 
by neuralgic pains and tingling in feet and hands. Then comes the 
paralysis in feet, legs, hands, and arms. This is either limited to 



DISEASES OF THE NERVOUS SYSTEM. 965 

this extent, or all the muscles are involved. The sensory symptoms 
may stop at the numbness and tingling, or lead to severe pain, with 
soreness of the muscles. There is oedema in the extremities, and the 
skin reflexes are preserved while the muscle reflexes are lost. 

Fortunately the prognosis is favorable, though convalescence may 
be prolonged, a not unfortunate circumstance, as it gives a greater 
chance to wean the patient from his (or her) bad habits. In this 
form of peripheral neuritis, the symptoms of the so-called steppage 
gait is most marked. It must not be mistaken for a tabetic gait, for 
the foot is thrown much higher, as if stepping over obstacles, and 
the incoordination is not so obvious. The mental symptoms are 
quite striking in this alcoholic form, for delirium is common, with 
hallucinations of grandeur (see general paralysis). Even delirium 
tremens has been noticed, though Wilkes' striking symptom of loss 
of appreciation of time and space, delusion of long journeys, contin- 
ual conversations, etc., is a remarkable form of an alcoholic mania. 

Treatment especially directed toward ameliorating the poison and 
effects of alcohol should be maintained. Reduce the stimulant as 
rapidly as possible without depressing the heart too much, and be 
careful to avoid opium ; one habit is as bad as another. 



LEAD AND ARSENIC POISONING. 

It is probable that the slow and steady use of arsenic leads to 
tolerance, and that only the rapid absorption of a non-lethal dose 
produces a neuritis. The general symptoms are not unlike those of 
alcoholic poisoning. The steppage gait is characteristic here. Lead 
shows its evil effects upon the system in many ways when the " palsy " 
appears. If it be a true neuritis, in addition to the general symptoms 
of blue gums, colic, and anaemia, we have the wrist-drop symmetric- 
ally developed (the type), or the brachial form, involving the del- 
toid, biceps, brachialis anticus, and supinator longus ; the Aron- 
Duchenne form, involving the small muscles of the hand (see polio- 
myelitis anterior chronica), or the laryngeal form, or the peroneal 
form. This lead neuritis comes on slowly without fever. 

Treatment. — In the colic stage morphine may be given and watery 
purges freely used. Avoidance of sources of absorption and a per- 
sistence in massage, electricity, and fresh air will often cure. 



966 THE PRACTICE OF MEDICINE. 

BERI-BERI, KAK-KE (Endemic Neuritis). 

This is a wide-spread disease, having its habitat in Japan, India, 
and the islands of the surrounding coast ; it probably depends upon 
a specific organism that leads to a multiple neuritis ; beyond this 
fact, much remains to be investigated. Europeans seldom suffer, but 
there is a predisposition engendered by a continuous diet of fish or rice. 

Symptoms. — The course is usually chronic (with occasional acute 
manifestations), gradual in its onset, and the symptoms are typical 
of a peripheral neuritis always symmetrical. 

Pekelharing, who investigated the disease in the East Indies at 
the instigation of the Dutch Government, says that even if the 
patient declares himself quite well, signs of neuritis can be discov- 
ered before the actual symptoms show themselves. 

The legs are chiefly affected, and in this case the cardiac branches 
of the vagus, showing heart failure and dropsy. The urine is les- 
sened in amount, or even suppressed ; there is no albumin. 

The earliest symptoms found by Pekelharing were changes in the 
electrical reactions (i. e., a reaction of degeneration), in the flexors 
of the ankles. The subjective symptoms are heaviness of the legs, 
weariness, diminution of tactile sensibility, with palpitation of the 
heart. Then begins the dropsy (in the legs first), the face has a 
peculiar doughy appearance, and the heart sounds are roughened. 
Sensibility to touch is lost, to pain preserved, giving an anaesthesia 
dolorosa. Other nervous symptoms of neuritis are common. Death, 
if it comes, finishes the scene in from two to six weeks, and is due 
to oedema and heart failure. 

The diagnosis cannot be mistaken if there is an epidemic ; other- 
wise the first symptoms may be ascribed to alcoholic neuritis, but it is 
well to remember that in the alcoholic form the legs and arms are 
apt to suffer together, and there is but little heart failure or oedema. 
The two may occur at the same time, however. 

Treatment — It is to be hoped that a method of prophylactic in- 
oculation may be found. At present, the treatment must be that of 
neuritis in general, especial care being taken to sustain the heart, 
not by large doses of digitalis and strophanthus, but by small fre- 
quently repeated doses. In this, as in other forms, rest is absolutely 
essential. 



DISEASES OF THE NERVOUS SYSTEM. 967 



NEUROMA. 

Many new growths may have their seat on the nerves, especially 
fibromata, secondary carcinomata, and syphilomata, but a true neu- 
roma does occur, as demonstrated by Virchow. Here an increase of 
nerve fibre with ganglion cells can be made out. The cause is obscure 
except in the case of traumatic amputation neuroma, where the tumor 
occurs at the end of a nerve left in a stump ; this may be simple or 
multiple. 

If the tumor occur in the course of the nerve it may cause no 
symptoms, or it may be very painful, with paralysis of the muscles 
supplied below. If the tumor can be felt, and is painful, and if sin- 
gle, it may be cut out, care being taken that in case it infiltrates the 
nerve itself, it be carefully removed and the divided ends of the 
nerves sutured. In amputation neuromata excision is always prac- 
tical. If syphilis is the cause, mercury and the iodides take the place 
of the knife. 



MYELITIS. 

(Inflammation of the Spinal Cord, Acute, Sub-acute, and Chronic.) 

Softening of the spinal cord, a term sometimes applied to an in- 
flammation of its substance, is not proper, as the result is not always 
softening, nor does softening always necessitate an earlier inflamma- 
tion. As the spinal cord does not, as soon as other organs, regain 
its function after an inflammatory disturbance, the terms acute or 
sub-acute have a significance relative principally to the mode of onset. 
The symptoms as a whole may be the same, but they appear with 
greater or less rapidity, together or following each other, as the case 
may be. For practical use, an inflammation of the cord presenting 
all the symptoms within two weeks of its onset may be called acute ; 
if two to six weeks elapse, sub-acute, and any longer period necessary 
to give a picture of the disease may properly make the case chronic. 

Though undoubtedly many of the symptoms of chronic myelitis 
simulate and are even indistinguishable from the results of sclerosis, 
yet, as a diagnostic fact, the distinction must be adhered to that 
chronic myelitis is an inflammation, scleroris a degeneration of a 
slower growth with no febrile antecedent, and often can be definitely 



968 THE PRACTICE OF MEDICINE. 

traced to such causes as syphilis and alcohol, and my purpose can be 
better served by giving only an outline of the symptoms in various 
phases of diseases of the spinal cord, with a few hints as to imme- 
diate treatment, advising the student to consult more special text- 
books for his intimate pathology and therapeutics. 

The causes may be cold, damp, exposure of any kind, injury, 
fevers, and other diseases of impaired vitality, lead and other poisons, 
syphilis, and chronic degenerations of the cord itself. 

The whole area may be involved, or only certain tracts, and ac- 
cording to the extent of the lesion do we use the terms general myel- 
itis, or transverse, focal, disseminated, etc. 

The most conspicuous symptoms are those that show an interfer- 
ence with the functions of the cord, and these may be the first signs 
of disease, but generally a slight febrile state precedes the decided 
evidence of paralysis, which in any case comes on rapidly, with weak- 
ness in one or more limbs, numbness, tickling, prickling, trembling, 
or cramps. The patient then becomes so helpless as to stay in bed, 
and he may lose control of the bladder and rectum. The numbness 
leads to anaesthesia, with a band-like feeling around the body, indi- 
cating the line of inflammation. If the inflammation extends upwards, 
then the anaesthesia and paralysis rise higher in proportion. Dis- 
orders of nutrition in the affected parts follow, blisters form on the 
feet, bed-sores and sloughs appear, or there may be a multiple ar- 
thritis. If the disease extends as high as the cervical region and 
medulla, the muscles of respiration may be involved, and death fol- 
lows. 

The diagnosis is difficult only with regard to multiple neuritis 
and meningitis ; but in multiple neuritis there are no trophic dis- 
turbances, and in meningitis the febrile symptoms, pain, and mus- 
cular rigidity are most marked, while in myelitis these sink into 
insignificance beside the paralysis and anaesthesia. 

A distinct variety may be alluded to as Compression Myelitis^ 
due to pressure on the cord from an injury, in which case the symp- 
toms appear suddenly ; or to a tumor, or caries of the spine, in which 
case the onset is gradual. The pressure exerted in any case can 
extend over only a few inches, and on the post-mortem table, if not 
clinically, the cord and its surrounding neighborhood show plainly 
enough the results of pressure. The most striking characteristic of 



DISEASES OF THE NERVOUS SYSTEM. 969 

such pressure is disturbance in the function of the cord at the involved 
area ; pain along the course of the nerves supplied by it, paralysis 
in the muscles, and only after local symptoms are manifest do signs 
of a general myelitis appear. 

Treatment. — If the very first stage of a myelitis due to cold is 
discovered, the usual treatment for an inflammation of this nature 
should be adopted ; a hot bath, free diaphoresis and counter irrita- 
tion, but if paralysis has begun it is best to insist on complete rest 
at once ; rest, not on the back, but with enough support to the back 
to adopt the sitting position ; a mild counter-irritant is useful, as a 
blister, for example. Otherwise, the treatment in the early stages 
can be aimed merely towards keeping the patient comfortable. Keep 
the bowels open, and counteract toxaemic conditions. Brown-Sequard 
advised ergot ; belladonna has its adherents, but there is really no 
specific. Prevent bed-sores, watch the skin carefully, keep the blad- 
der healthy, and guard against contractions by proper splints. As 
the stationary stage comes on, more freedom of movement may be 
allowed, and tonics must be resorted to, including massage ; electric- 
ity has no influence over the cord, but is a good agent when a mild 
current is applied to keep up the tone of the affected muscles. 

In sub-acute and chronic cases, preserve the general health by a 
change of air, tonics, and proper mental and moral surroundings. 
Avoid over-exertion or exposure to cold. Do not insist on complete 
rest. Sea baths, counter irritation with blisters or the actual cau- 
tery, are at times useful. 

The drugs indicated by the symptoms are aconite, bryonia, cieuta, 
arsenicum, agaricus, gelsemium, phosphorus, hyoscyamine, physo- 
stygma, turnera (damiana), picric acid, ergot, ignatia, nux vomica, 
strychnine, and phosphide of zinc. (For special indications, see Lil- 
ienthal and Raue.) 



ACUTE MYELITIS OF THE ANTERIOR HORNS OF THE 
SPINAL CORD. 

Atrophic Spinal Paralysis, Acute Atrophic Paralysis, Infantile 
Spinal Paralysis, Acute Poliomyelitis Anterior — any of these terms 
may be used to designate a disease of the spinal cord occurring most 
frequently in children, and manifested by symptoms showing an 



970 THE PRACTICE OF MEDICINE. 

impairment of the anterior horns particularly, rather than of the 
whole cord itself. 

Though cold is a decided cause, it may follow any of the erupt- 
ive fevers or a diarrhoea, or appear suddenly in perfect health. 

Symptoms. — The onset is usually sudden, with only a premoni- 
tion in the way of general debility and malaise. A fever of short 
duration most always accompanied by vomiting is followed by the 
essential symptoms of a widespread, rapidly developing paralysis that 
may include even all the four limbs, but which seldom lasts in its 
original severity, most muscles regaining their normal functions ; but 
the paralysis always in its retrogression leaves some one set of mus- 
cles distinctly affected. The lower extremities most often suffer, and 
though hemiplegia is rare, it does occur. Pain is not necessary, but 
when present it is referred to the muscles, or to the joints, as it is 
most acute on motion, but its real nature is a neuritis independent 
of, but associated with, the myelitis. The sphincter muscles usually 
escape, though there may be incontinence of urine, either temporary 
or permanent. Sensory disturbances, beyond the pain mentioned 
above, are absent, except in extreme cases (one in fifty, Gowers). 
The reflexes in the parts related to the paralyzed muscles are lost. 

After the initial paralysis is fully developed a period of greater 
or less extent supervenes before improvement sets in. This improve- 
ment shows itself in the parts last affected, and thus continues till 
there remain only those muscles that are to show a lasting injury. 
By careful examination it may be seen that these muscles are tone- 
less and flaccid from the first, and a distinct wasting distinguishes 
them from the others, so that the limb loses its normal shape. Fat 
children may present some difficulty to the diagnostician, for an 
interstitial growth of fat masks the genuine wasting. There may be 
a tenderness to the touch. As a result of the muscle atrophy the 
limb is deformed, either by an actual disease of the bone or by the 
weight of the limb (Volkmann), added to a predominant action of the 
healthy muscles and the loss of function in the diseased muscles. 
There is no longer faradic irritability (contraction), and the reaction 
of degeneration is present in its characteristic form. The affected 
part is at first slightly elevated in temperature, but as paralysis 
increases the limb is colder than normal. The course of the disease 
shows three stages (Gowers) : (1) An initial stage of paralysis, 



DISEASES OF THE NERVOUS SYSTEM. 971 

varying from a few hours to a week or more. (2) A stationary 
stage of one or more weeks. (3) A stage of regression, in which 
the paralysis disappears except from those parts that are to remain 
permanently diseased. Death is uncommon, relapses are rare, and 
sequalae are not marked except an inclination of the cord toward 
other inflammations. 

Apply to adults the same conditions of acute paralysis, with or 
without fever, exclude cerebral affections, mark the nearly complete 
recovery from the original general muscular involvement, with a 
limited permanent loss of function in some set of muscles, and the 
same picture holds good for acute poliomyelitis in adults as in chil- 
dren. 

Pathology. — Investigation points to an inflammation limited to 
the grey matter of the anterior horns of the cord, with probably a 
tendency to hemorrhages into the cord, greater in this case than in 
that of a general myelitis. 

Another distinct type of myelitis, in this case designated as acute 
ascending paralysis (" Landry's Paralysis "), is well marked enough 
to be called by Hun (" New York Medical Journal," May 30, 1891) 
" A Clinical Entity," though " no corresponding lesion has as yet 
been disco vered." Here we have the weakness of the legs, some- 
times increasing rapidly, passing to the arms, and finally involving 
the medulla. There is no muscular atrophy, but the reflexes are 
lost. Sensory phenomena are not prominent, though there may be 
some tingling sensations. The electric reactions are preserved and 
no muscular atrophy appears. The mind remains clear, but death 
is the rule, occurring about ten days from the beginning of the dis- 
ease, I have called this a myelitis, though the pathology is by no 
means so evident as that of the common form of myelitis. By some 
it is disputed whether the spinal cord is at all the primary seat of 
the lesion, ascribing it rather to a blood disturbance that manifests 
itself chiefly upon the nervous elements in the anterior horns, either 
as a poison or as a hemorrhagic affection. 

The symptoms are, however, so closely allied to a rapid inflam- 
mation of these anterior horns that for practical purposes it may be 
included in this chapter. 

Treatment. — Nothing can be added beyond the hints given under 
Acute Myelitis. Especial care should be taken to keep the child on 



972 THE PRACTICE OF MEDICINE. 

the side, so as to prevent a stasis of blood in the cord. Hot foment- 
ations seem to give marked relief and should always be tried. Even 
if belladonna or ergot do no good they certainly are harmless, and 
can be used without fear. 

Perfect rest is advisable for two weeks after inflammation has 
subsided, and not until the stationary stage is assured or even improve- 
ment has set in can some motion with tonic treatment be authorized. 
Here strychnine seems to be of great service if used properly, for 
though it may be said that power will be regained without medicine, 
yet the drug is a great stimulant, and if carried only to the extent 
of aiding the nerve recovery it has no equal. 

Electricity is an important agent, but it must be understood before 
the benefits it is capable of can be secured. One fact must be always 
borne in mind. It does not influence either the nerve or the spinal 
cord, but it does help to maintain the nutrition of muscle, and while the 
nerve is getting well the muscle must be encouraged to do likewise. 
If the muscle fibres are excited from time to time by electricity, their 
sensitiveness to stimulation is distinctly increased, not only to elec- 
tricity but to the voluntary stimulus. " Wherever cell and fibre have 
perished nothing that electricity effects can be of service ; but where 
there has been damage, not destruction, and the fibres slowly recover, 
but regain their influence on nutrition and their capacity for convey- 
ing impulses only after some months, the failure of muscular nutri- 
tion may be disproportionately great, and may even render useless 
some regained nerve power. This result electricity is probably able 
to prevent. The electrical treatment may be commenced at the end 
of the third or fourth week after the onset. It should not be used 
earlier, lest it excite increased disturbance in the spinal cord. The 
application need only be made to those muscles in which faradic 
irritability is lowered or lost." 

The galvanic current is the best, applied locally to the muscle, 
with gentle, frequent interruptions. Be sure to get contractions, but 
avoid giving pain, and encourage the patient to see the harmlessness 
of the battery. Massage and rubbing are equally important ; use 
no liniment, but keep the limbs dry and warm. 

As soon as some voluntary power comes back, encourage exercise, 
at first passive, then active, and by any convenient device avoid 



DISEASES OF THE NERVOUS SYSTEM. 973 

awkward contractions by appliances suited to prevent spinal curva- 
tures, talipes equinus, etc. 

Do not claim too much credit for your treatment ; give nature her 
due in this disease, reserving for yourself the modest praise of hav- 
ing helped her powers. 



MULTIPLE SCLEROSIS OF THE BRAIN AND 
SPINAL CORD. 

(Disseminated Cerebro-Spinal Sclerosis, Insular Sclerosis, 
Sclerose en Plaques.) 

Multiple sclerosis is a chronic disease, the anatomical explana- 
tion of which is to be found in the development of numerous unsym- 
metrical sclerotic patches, scattered irregularly in the brain, or cord, 
or both. It is observed in youth chiefly, though cases have been 
seen at sixty ; the etiology is very obscure ; it is said to follow blows, 
excitement, and catching cold. The eruptive fevers encourage it, 
and heredity plays some part in the cause ; syphilis is a mere acci- 
dent. The development is slow, remissions are possible, but the 
prognosis is bad, and death is certain. The most important symp- 
toms may be emphasized as follows : 

(1) Tremor, rather volitional than continuous, absent when at 
rest, but aroused and exaggerated on voluntary motion. In this it 
differs from the continuous tremor of paralysis agitans, and a good 
diagnostic distinction can be noted on asking the patient to drink a 
glass of water. In multiple sclerosis he can hardly, if at all, get it 
to his mouth. This tremor is irregular, jerky ; the tongue and lips 
partake of the trouble, and partly on this account, partly on account 
of a central lesion. (2) The speech becomes slow, accented, stac- 
cato, scanning, indistinct, and finally unintelligible. The voice is 
monotonous. (3) Nystagmus. 

The strength of the muscles is retained, though there may be 
paresis and even paralysis. Oftener, however, there are spastic 
symptoms, depending as a general thing upon the " increased re- 
flexes," and more marked in the lower than in the upper extrem- 
ities ; this increased reflex may pass into the condition known as 
" spinal epilepsy," and is induced by a blow on the tendons, or 



974 THE PRACTICE OF MEDICINE. 

attachment of muscles to bones. The gait is slow, passive motion is 
retarded, but sensibility is not markedly interfered with. Bladder 
and rectal symptoms are seldom found. The cerebral power is, how- 
ever, depressed ; there may be weak-mindedness, melancholia, and 
even imbecility ; apoplexy has been an intercurrent trouble, or epi- 
lepsy and simple vertigo is not at all uncommon. 

The symptoms mentioned belong to a typical case, but many 
instances can be found of an untypical character that confuse the 
diagnosis or render it impossible till a post-mortem examination 
shows the brain and cord degeneration. When the characteristic 
gait, disturbance of speech, and nystagmus are present the diagnosis 
is easy ; otherwise the best of clinicians may mistake. 

Treatment must follow the line as suggested for chronic myelitis, 
the symptoms of the disease and of the general health being met as they 
arise. Nerve vibration is always to be carefully considered in the treat- 
ment of the disease. The treatment is primarily directed to stimu- 
lation and reeducation through function and the absorption of adven- 
titious tissue; secondarily to producing rythmical vibration to subdue 
tumultuous and irregular vibrations of the nervous elements, and thus 
restore orderly functions. First, apply the disk over closed eyelids 
with very light pressure and a rapid vibration ; second, apply disk 
over the auditory meatus, a slower vibration ; third, apply large ham- 
mer to tongue, small hammer in anterior nasal cavity. Then small 
hammer to all points on body where nerve trunks lie very near the 
surface, and lastly over each spinous process. Operation should be 
repeated daily. 



CHRONIC DIFFUSED MENINGO - ENCEPHALITIS. 

(General Paralysis of the Insane, Dementia Paralytica, 
General Paralysis.) 

Although from a symptomatic point of view general paralysis is 

generally classified with mental diseases, and treated in the special 

text-books of the alienist, yet fortunately the pathology in this case 

has escaped the realm of the imagination, and become a matter of 

exact clinical and post-mortem macroscopical and microscropical 

investigation. It may be said that many other diseases demanding 

the care of the alienist, and manifesting signs of mental perversion, 



DISEASES OF THE NERVOUS SYSTEM. 975 

are traceable to a distinct morbid process ; but as a fact of pathology- 
such is not up to now the case. The symptoms of many kinds of 
insanity may be the same, yet a greatly differing pathological course 
may be found at work. The cause then is only individual and acci- 
dental, but in general paralysis all cases are found to have only one 
underlying pathological cause ; therefore, to reverse the rule, demon- 
strate this underlying pathological condition, and most probably there 
will be found symptoms of a General Paralysis of the Insane. There- 
fore it has been thought best to mention it here, especially as the dis- 
ease, in its early manifestations, is one that often demands the knowl- 
edge of it from the general practitioner. 

Definition. — A gradual loss of the power of coordinated move- 
ments, accompanied by gradually increasing mental disturbance and 
decay, ending in dementia and paralysis, due to a chronic progress- 
ive meningo-encephalitis. 

Pathology. — Essentially a sclerosis of the brain tissue ; an atro- 
phy of the brain, attacking particularly anterior halves. The pia 
mater is thickened and in places adherent to the cortex. The ves- 
sels are tortuous, and there may be arterio-sclerosis. The convolu- 
tions are atrophied in spots, and in fresh cases, there may be gen- 
eral or localized signs of an inflammation. There is also a degen- 
eration of the axis cylinder of the nerve fibres and of the gan- 
glion cells. Mendel uses the expression, an interstitial encephalitis . 
Struempell believes the process to be a primary degenerative atrophy 
of the nerve bundles and cells, to which the increase in connective 
tissue is secondary. In the spinal cord there is more or less exten- 
sive change, marked by degeneration of the pyramidal or posterior 
tracts. (See Tabes.) 

Etiology. — Males from thirty to fifty, married, suffer more than 
females ; the patients come more frequently from the cultured classes. 
Heredity, especially of a neuropathic constitution, plays a minor 
part, but business worry, added to excess of all kinds, particularly 
alcohol, can seldom be eliminated, while syphilis accounts for seventy- 
five per cent of cases. 

Prognosis and Causes. — The disease when once developed is 
incurable, though spontaneous remissions are not uncommon ; but 
death is sure to follow in from two to fifteen years, due either to 
exhaustion or to some intercurrent malady. 



976 THE PRACTICE OF MEDICINE. 

Symptoms (First Stage). — It is hard to establish a beginning 
to the disease, for a change in disposition is often its earliest and 
only manifestation. The patient cannot do his work well, his mem- 
ory fails, his habits alter and he becomes disorderly ; his judgment 
plays him false, while his temper may be abnormally irritable. He 
plots, speculates, and grows extravagant, boastful, till his family 
wonder " what has changed him so." Meanwhile there may be fre- 
quent complaints of poor health ; subjective sensations of headache, 
rheumatism, vertigo, sleeplessness, and indigestion, but even in this 
first stage, when a patient to all intents and purposes a neuresthenic 
applies for treatment, two diagnostic signs are of vital importance : 
(1) The loss of power of mental conservation (the best test is a 
sum in multiplication), and (2) phenomena of motor disturbances. 
Watch carefully for tremor of the tongue and lips in speaking, slow- 
ness of speech, inequality of pupils, and an awkwardness in hand- 
writing. 

(Second Stage.) — This is characterized by mental exaltation and 
pronounced motor disturbance. The delirium may be extravagant, 
hypochondriacal, or melancholic, or there may be a passive self- 
satisfied state. Mania can develop; most always there is great 
restlessness, sleeplessness, excitement, violence. Here, if anywhere, 
are observed the ideas of grandeur, that make the patient claim to 
be of fabulous wealth, to have the most beautiful wife and children 
in the world ; to be a king with millions at his feet, etc. If these 
■" ideas of grandeur " are escaped from, the other extreme of excessive 
melancholy generally develops, or the two may alternate ; and mem- 
ory gradually fails. At this period the motor symptoms can no 
longer be overlooked or mistaken. 

The writing is bad or illegible ; the speech slow, stammering, one 
syllable runs into the other, and the tongue, lips, or even the facial 
muscles, twitch abnormally. The pupils are unmistakably involved 
with a loss of reaction to light ; the reflexes are diminished (tabetic) 
or increased (spastic). Neuralgia is not uncommon, nor are attacks 
of vertigo, or even apoplectiform seizures and paralysis. Epilepsy 
(Jacksonian) is frequent, usually on one side. The gait is impaired, 
the patient trips readily, and cannot go smoothly up or down stairs. 
Sexual desire is increased, and when there is no restraint great excess 



DISEASES OF THE NERVOUS SYSTEM. 977 

may be indulged in even by the most virtuous. Then degeneration 
advances rapidly, the bladder and rectum are lost control of, the 
patient becomes bed-ridden) and dies completely demented. 

Diagnosis. — As the family physician is always the one under 
whose observation the patient first comes, it is necessary that the 
earliest symptoms should be well studied, so that the man himself 
and his family and friends may be put on guard, and a proper prog- 
nosis given, with an attempt at the only rational treatment, rest and 
restriction. To repeat, the salient symptoms are a distinct change 
in temperament, great increase or depression of spirits, loss of mem- 
ory, weakness of intelligence, the characteristic effects on speech and 
writing, and bodily weakness ; add to this the loss (or exaggera- 
tion) of reflexes, slight motor paresis, mild paralytic attacks, and 
rigidity or inequality of pupil. With such symptoms, and a history 
of excess, or syphilis, or business worry, the suspicion passes into 
certainty. A mistake in diagnosis may lead to one of the saddest 
errors of professional or social life. A man can be ostracised, perhaps 
driven from home and friends and ruined in business, because he had 
violated some moral law ; the world finally points with scorn at him, 
and uses as an example of retributive justice the fact that his death 
occurred in a madhouse, whither his remorse had driven him. But 
had the skilled physician seen this sinner when first his system broke 
down, had his moral offences been recognized as part only of the 
general physical decay from the meningo-encephalitis, then the cause 
would not have been confused with the effect, warning might have 
been given, and even though no cure were possible, a good man's 
name might have been saved from obloquy and his days ended peace- 
fully under the watchful care of an asylum. 

Treatment. — All excitement and business must be stopped, and 
the patient removed from his usual surroundings, but the actual con- 
tinuous treatment can be carried on only in a properly equipped asy- 
lum, and every inducement should be urged for the patient's resi- 
dence there. Individual symptoms can be treated as they arise, but 
the least suspicion of syphilis should be followed by a resort to mer- 
cury and the iodides ; while the early stages of excitement and cere- 
bral inflammation may be softened by warm baths ; careful electri- 
zation can be tried ; ergot has been recommended. 



i 



978 THE PRACTICE OF MEDICINE. 

CHRONIC DEGENERATIONS OF THE SPINAL CORD. 
(Locomotor Ataxy, Tabes Dorsalis.) 

This disease is by far the most common of the sclerotic affections 
of the spinal cord. The symptoms vary much in individual instances, 
but the general manifestations combine always the essentials of the 
peculiar girdle pain, defective sensibility, incoordination of movement, 
and the loss of myotatic irritability (muscle reflex, the type of which, 
and the symptoms always used in examining for diagnosis, being the 
knee-jerk). 

The intellectual city classes are attacked oftener than the inhab- 
itants of the country, and males much oftener than females. The 
disease is generally one of the prime of adult life, from thirty to fifty 
years, heredity playing a subordinate part, and the influence of syph- 
ilis far outweighs any other cause, some authors claiming as high as 
eighty per cent. Strange as it may seem, however, the analogy does 
not extend into the pathology or treatment, for the lesion is a purely 
degenerative one, and syphilitic treatment has an acknowledged lack 
of effect on the course of this degeneration. Cold, injury, and over- 
exertion are exciting if not immediate causes. The course of tabes 
cannot be stated with accuracy, as one case may end in death within 
a year, while a second case may develop only certain symptoms, 
remaining stationary thereafter for a good part of the lifetime. 

There are three stages into which the disease may be classified, 
(1) the initial loss of reflex action with the pains, (2) the beginning 
ataxia, (3) complete incoordination. 

In itself, tabes is not fatal, but it leaves the general system such 
an easy prey to intercurrent maladies, that life is certainly shortened 
thereby. Myelitis, either acute or subacute, may develop from tabes, 
as well as other lesions of the cord, even to an invasion of the ante- 
rior cornua ; but the muscular atrophy incident thereto is not itself 
a sign of tabes, and should not be confusing to the diagnosis. 

Tabes has a distinct relationship to General Paralysis, depending 
probably on the syphilitic origin, and one disease may simulate the 
other, or run into the other, till a dominance of one or the other is 
reached. 

Valvular heart disease is a common complication (the cause here 
may be the syphilitic infection). 



DISEASES OF TEE NERVOUS SYSTEM. 979 

Pathology. — Of the pathology it can here be said only that essen- 
tially it consists of a sclerosis of the posterior columns. All else is 
dependent on individual manifestations of symptoms that shows an 
involvement of other cord tracts or nerve fibres. The histology 
should be studied by itself, from text-books dealing with the sub- 
ject in a more technical way : undoubtedly there is a pronounced 
involvement in advanced cases, of the tracts of nutrition and of the 
end nerve fibres in bone and cuticle. 

Symptoms. — A typical case of tabes must present three symp- 
toms : (1) The " lightning " pains of a sharp, momentary character 
in the affected parts, and the "girdle" pains of a constrictive char- 
acter ; (2) a loss of reflex action, most pronounced in the typical 
" knee-jerk," and (3) incoordination of movement, generally in the 
movement of the legs, but sometimes in the arms or other muscular 
functions. The pains and the loss of knee-jerk precede the other, 
but with these three undoubtedly present, the diagnosis must not be 
doubted. 

The " knee-jerk " is familiar to everyone. The " lightning " pains 
compel mention by the patient, but the incoordination may need 
some deftness in detection. What is called "Romberg's sign" is 
the earliest test. Let the patient stand with his feet close together, 
the heels and toes touching each other ; then, with his eyes closed and 
arms extended, watch his movements ; most people subjected to this 
examination will at first feel insecure, but a tabetic patient will fall. 
This sharp distinction can be drawn, that if a patient fails to main- 
tain equilibrium after repeated trials, incoordination is present. Other 
minor symptoms need mentioning, as they help in the diagnosis. 
Atrophy of the optic nerve is common, and trophic changes in the 
joints, bones, and skin ; in fact the skin manifests many changes, 
both objective and subjective, of a neuritis. Spontaneous pain oc- 
curs frequently, at any part of the body ; paroxysmal, most severe 
at night, lasting for a few minutes or a few hours ; they may corre- 
spond to a nerve trunk or may have no relation to a nerve. Instead 
of lightning, or stabbing pains, they may be burning and cause great 
distress. All sorts of parasthesic sensations may be complained of, 
as tingling, creeping, heat, and cold, or increased or diminished sen- 
sibility. Sensation may be delayed, or perverted ; or a touch in one 
limb may be ascribed to the other. The sole of the foot may lose 



980 THE PRACTICE OF MEDICINE. 

its sensations ; sometimes the change in sensations lies deeper than 
the skin, so that the muscles do not notice any force exerted upon 
them, or the patient cannot tell the position of the limbs ; in such 
cases severe injuries may escape detection. Pleurisy, for example, 
may be painless. Loss of sexual power may be an early symptom. 

The Argyll-Robertson sign, in which the iris reflex is lost to light, 
but retained to accommodation, is a very common symptom (five- 
sixths of all cases, Gowers), and transient weakness or paralysis of 
one or more eye muscles, with ptosis, can often be noticed. Blind- 
ness, due to optic nerve atrophy, may appear. There may be deaf- 
ness and loss of smell, but it is hard to distinguish these symptoms 
objectively. All the sphincters may suffer, and indeed a chronic cys- 
titis due to paresis of the urethra may be the first symptom com- 
plained of by the patient. 

What has been called " perforating ulcer of the foot " has been 
found to be almost confined to tabes, and this trophic disturbance, 
together with others of the skin, as ecchymoses, pigmentation, will 
need attention. Spontaneous fractures are common, and these, 
together with painless swellings of joints, should arouse a suspicion 
of tabes, and finally, the visceral and laryngeal symptoms, what the 
French call " crises " may be the first evidence of the disease, partly 
on account of the non-association with catarrhal trouble, partly 
through their slow response to treatment. Extreme and prolonged 
vomiting, with pain sometimes without nausea, may give a great deal 
of trouble, and spasm of the larynx may threaten, and even, though 
rarely, cause sudden death. Such are the ins and outs of tabes ; all 
these symptoms need not be expected, but any one may be looked 
for, and any one, with no immediate cause, must lead the physician 
to examine most carefully for the essential signs. 

Treatment. — There is no doubt about the favorable effects of treat- 
ment in tabes, if carried out with perse verence and method, though 
it is by no means safe to promise a cure, or even to feel sure of an 
amelioration in some cases. To retard the disease, however, to make 
the patient comfortable even if the pathological process cannot be 
stopped, is a great encouragement to our art. 

When the first signs of an initial tabes are detected the patient's 
habits of mind and body must be carefully regulated. Any over- 
exertion, any excess or worry, must be stopped, and the surround- 



DISEASES OF THE NERVOUS SYSTEM. 981 

ings made pleasant and healthful. Fatigue in walking is to be avoided, 
though gentle exercise is not harmful. Falls are particularly dan- 
gerous, as an acute inflammation may be started, or bones may be 
broken. Indigestion must be prevented if possible, for it often sets 
up a crisis of pain that might otherwise have been escaped. The 
same is true of constipation and catching cold. Smoking must be 
limited, and alcohol completely stopped. We have seen how an alco- 
holic neuritis can give symptoms akin to tabes. Sexual commerce, 
if admitted, should be at only infrequent intervals. 

The first question in the use of drugs is in reference to an anti- 
syphilitic treatment. It is wise always to suspect syphilis, and act- 
ing on this suspicion to try a course of inunction or internal medi- 
cation with small doses (one-sixteenth of a grain of red oxide) of 
mercury, which so used has a good tonic effect anyway. If the sec- 
ond stage of syphilis has already appeared, use the iodide of potas- 
sium. This drug has an undisputed curative influence over syphilitic 
locomotor ataxia, but not in the minute doses of our school, or the offi- 
cinal doses of the old school. Except in rare cases these are power- 
less. I have had under my care within the last ten years severe cases 
of syphilitic ataxia which did not improve under iodide of potassium 
or any other drug. I used the former in doses ranging from lx to 
ten grains of the crude drug three times a day. Finally they all con- 
sulted and were treated by a physician notorious for giving massive 
doses of iodide of potassium. While under his care these patients 
were given half an ounce per diem of this drug for several months, 
with an occasional intermission of a few days. They were benefited, 
as I know from personal observation. 

Aurum mur. et sodii is another valuable remedy for syphilitic 
ataxia when the physical and mental symptoms call for its use. The 
2x trituration in three to five grains three times a day is the proper 
dose. In non-syphilitic ataxia, if it ever exists, many medicines have 
been used by both schools. 

Arsenic is highly valued by the old school. Gowers (" Diseases 
of the Nervous System ") says : " Arsenic is certainly a drug which 
most frequently does distinct good. Most of the cases in which I 
have known the greatest improvement to occur have been taking it 
at the time." He says it seems best indicated when there is also 
degeneration of the cutaneous nerves. (It causes peripheral neuri- 



982 THE PRACTICE OF MEDICINE, 

tis with degeneration.) Raue gives a few indications for arsenic, 
but Lilienthal does not mention it. Donovan's solution, arsenic and 
mercury, is credited with many cures. The dose should not exceed 
ten drops of the lx dilution. It is a notable fact that the chlorides- 
of many metals are efficacious and that most of them are anti-syph- 
ilitic agents. Boenninghausen recommends aluminum highly, while 
Gowers says he " has found the chloride of aluminum of distinct 
service." 

Nitrate of silver is of undoubted value, as the testimony of both 
schools shows. The provings show it to be capable of causing a sim- 
ilar condition. The chloride of silver is highly esteemed by Dr. 
Delamater and others. The chloride of barium (baryta mur.) is 
often indicated in advanced cases in the very old, and Hammond 
has lately advocated its use in small doses. There are symptoms in 
the provings of platinum which indicate that the chlorides of that 
metal ought to be useful in ataxia. 

Other most important medicines in ataxia are phosphorus, nux 
vomica, and picric acid. Phosphide of zinc and picrate of zinc may 
in some cases act better than phosphorus, and strychnine better than 
nux vomica. Other medicines to be consulted are physostigma, rhus 
tox., cuprum, augustura, conium, hyoscyamus, and stramonium, but 
we cannot expect any curative results from such drugs ; they cannot 
arrest the sclerosis and other degenerative processes. 

A new and unique remedy, " cerebrine," prepared from the brain 
of animals, ought to be mentioned. Dr. Graeme M. Hammond, on the 
14th of April, 1893, presented to the New York Neurological Society 
a case of locomotor ataxia treated with hypodermic injections of cere- 
brine. Six years ago the patient, a man aged forty, had begun to 
suffer with double vision. This, after several months of treatment, 
had disappeared, and for a time he had been quite well. Then the 
typical symptoms of locomotor ataxia came on. There was complete 
loss of the knee-jerks ; he had sharp pains in his legs ; the ataxic 
gait was well marked ; there was inability to stand with his eyes 
closed, even when the legs were some distance apart ; he had diffi- 
culty in evacuating his bladder and bowels ; his sexual power was 
lost, and he had a sense of constriction around the waist. There 
were no eye-symptoms. The man denied syphilis. Treatment was 
begun about ten weeks ago, and consisted of a daily injection of cere- 



DISEASES OF THE NERVOUS SYSTEM. 983 

brine, five minims combined with five minims of water. The im- 
provement was marked. The man's sexual functions had been per- 
fectly restored ; he had complete control over his bladder and bowels ; 
the sharp pains had disappeared ; his general health had improved ; 
he was able to run up and down stairs, and could stand fairly steady 
with his eyes closed. The knee-jerk, however, had not returned. 
The improvement had been gradual and steady, and had begun about 
a week after the first injection. 

Struempell would discourage any excessive use of baths beyond 
a mild application of luke-warm water. Profuse sweatings by ex- 
tremely hot water or steam, so often undertaken for the false rheu- 
matic pains in tabes, are in his opinion decidedly harmful. The most 
a gentle warm bath can do is to lessen the girdle pains by soothing 
the nervous system. 

For these pains, antipyrin, acetanelid, phenacetin, or exalgin are 
useful and the least harmful. Cocaine hypodermatically, or a sim- 
ple liniment, may help the more superficial pains. If any pain grows 
too severe for these minor remedies, morphine must be resorted to. 

Laryngeal crises generally yield to amyl nitrite or to glonoine. 
Glonoine is also useful, in small doses combined with strychnine, to 
dilate the capillaries while the strychnine acts on the cord and nerves. 
The strychnine or nux vomica is undoubtedly efficacious in strength- 
ening the bladder, as is also belladonna or atropin, but too much 
dependence must not be placed upon it if there is any indication of 
continued residium of urine. A cystic catarrh must by all means be 
overcome, and no hesitation should interfere with a proper emptying 
of the viscus. In such cases the catheter must be constantly em- 
ployed, with due aseptic precautions. The electric current is of little 
influence over the actual sclerotic process, but it aids in subduing 
the superficial pains and in preserving as long as possible the normal 
tone of the muscles, and the proper tendency of the sphincters to con- 
tract. 

Such precedures as nerve stretching and extension are more fully 
discussed in technical works, but their utility is already a matter of 
grave doubt. 

In the treatment of non-specific ataxy, nerve vibration promises 
to become of the greatest value. Many long-standing and very 
advanced cases have through persistence in this treatment been per- 



984 THE PRACTICE OF MEDICINE. 

manently cured. The applications should be daily, as near as pos- 
sible at the same hour, and of the same duration, rapidity, and press- 
ure. At first apply small flat hammer over tendons at the root of 
the toes, then behind each maleolus at the ankle, over the entire 
surface of the soles of the feet, over the patella tendon, over along- 
course of sciatic, over crural at groin. After two or three months' 
treatment, continue by applying in addition over the spinous pro- 
cesses. 

The first effect is likely to be an exaggeration of the pains for 
a period of one to three weeks, followed by gradual diminution of 
pain and final cessation. In a few weeks there will usually be noticed 
a slowly advancing diminution of the exaggerated movements, fol- 
lowed by gradual approach to coordinate and finally complete coor- 
dination of motion. The treatment must be persisted in from one 
to three years, with only occasional but entire cessations of from two 
to four weeks. 

Spinal extension has received considerable attention in this and 
allied affections of the spinal cord ; while it seems to have gone out 
of fashion now, it is without any doubt of value in many cases, and 
should be used carefully and judiciously as an adjuvant to other treat- 
ment. 



PRIMARY LATERAL SCLEROSIS. 
(Primary Spastic Paraplegia.) 

Although theoretically, or from a physiological point of view, the 
above disease may be present in its typical form, practically the cases 
of pure lateral sclerosis are extremely rare, the symptoms being most 
always associated with those of ataxic paraplegia, to be described 
next. As, however, the essentials of a simple lateral sclerosis may 
be of value to the diagnostician, I give them here. 

Of the causes, much the same can be said as of locomotor ataxia, 
syphilis, injury, cold, and to some extent, heredity. The third and 
fourth decade suffer most, and no influence is shown by sex. 

Symptoms. — First of all comes weakness of the legs, complained 
of chiefly by a patient as noticeable after exertion that previously was 
not tiring. One leg may be weaker than the other. This weakness 
may be accompanied by unsteadiness, due to weakness (that is, sub- 



DISEASES OF THE NERVOUS SYSTEM. 985 

jective), not to incoordination. There is a loss of power in the flexors, 
and the knee-jerk is increased and quick. The foot clonus is demon- 
strable too. A tendency to spasm may be first noticed as a stiffness 
in the morning, which increases as power is lost, till the spasm is 
manifested on any extension of the joint, even to tonic spasm, " clasp- 
knife rigidity." 

The gait then becomes characteristic, for the leg drags behind, 
the toes catch on the ground, and the spasm may be developed by 
any attempt to bring the limb forward. Usually the limbs retain 
their normal shape, and electrical reaction is unaltered. Other 
muscles besides those of the leg may suffer, as the arm and trunk, 
but not often, and the " pains " complained of can be taken as a 
symptom of muscular weakness rather than of a nerve involvement. 

All these signs may show themselves in the infant. 

General Paralysis of the Insane, with only slight mental impair- 
ment, may show itself first in lateral sclerosis, as in tabes. This is 
a very chronic disease, the least dangerous to life of any degenera- 
tion of the spinal cord. Supposing the disease typical, the patholog- 
ical anatomy will give evidence of a sclerosis of the lateral columns 
of the spinal cord, analogous to that of the posterior columns in tabes, 
but any extension of this process beyond these lateral tracts brings 
us to the more general form of spinal cord weakness known as Com- 
bined Lateral and Posterior Sclerosis, or — 



ATAXIC PARAPLEGIA. 

A disease showing symptoms of both paraplegia and ataxy, com- 
bining some of the signs of a pure lateral sclerosis with those that 
can come only from involvement of the lateral columns and of the 
posterior columns, as in tabes, and proved by pathological examina- 
tion to be dependent upon just these conditions implied in the above 
name. 

Causes. — A distinct difference from tabes must be noted, for 
heredity plays but a small part, and " a history of syphilis is as rare 
as it is frequent in tabes " (Gowers). Middle aged males suffer most. 
Cold is an exciting cause, as well as injuries and sexual excess. 
Some cases seem to arise without cause. 

Symptoms. — The onset is slow ; walking is first impaired, thus 



$86 THE PRACTICE OF MEDICINE. 

resembling spastic paraplegia; there is stiffness and trembling of 
the lower extremities, with soreness and aching. Sensory symptoms 
are slight, however. To the early signs of spastic paraplegia, add 
ataxic unsteadiness, uncertain movement in the dark ; Romberg's 
sign, an awkward, tabetic gait, the patient using a stick for support. 
On lying, too, this unsteadiness is present, as it is hard for the 
patient to touch objects with his feet. In contrast to tabes, how- 
ever, sensory and reflex symptoms are absent, the only noticeable 
one being a dull pain in the sacral region. Myotatic irritability is 
exaggerated, and the knee-jerk is pronounced, and increases as the 
disease progresses. Sexual power is lost at an early stage and the 
sphincters commonly become involved. Eye symptoms are rare, but 
when present should start a suspicion of syphilis. Nystagmus can 
sometimes be found when the eyes are in motion. The incoordina- 
tion after a time remains stationary, but the paralysis increases, 
involving the arms and perhaps the head, while sensation is unaf- 
fected, and the mind, except in those cases that show a tendency 
toward General Paralysis of the Insane, is clear to the end. 

Departures from this type indicate a closer approach to tabes or 
a condition of chronic myelitis. 

Diagnosis. — Marked incoordination with retained reflexes, a slow 
progress, some spasm, and only slight sensory or ocular symptoms. 

Treatment. — Little can be added to the treatment of either 
lateral sclerosis or combined lateral and posterior sclerosis. The 
pathology being in all cases a sclerosis of the cord, and the treat- 
ment being in outline that suggested for a posterior sclerosis. It 
must be confessed that our knowledge of drug action on the spinal 
cord is very slight, and in such an apparently incurable disease as 
this we must be cautious in our reliance on medicines. Though 
strychnine has been recommended for posterior sclerosis (tabes), it 
must be watched very closely here, so as not to give it the extent of 
producing spasm by its physiological effect, as spasm is one of the 
very symptoms we here try hardest to combat. The bromides are 
sometimes useful to overcome this spasm, as are also cannabis indica, 
belladonna, and hyoscyamus, though the effect of none of these is 
lasting. Fatigue of any kind is harmful, whereas passive exercise 
with massage is often beneficial. 

Another departure from the routine treatment for posterior scler- 



DISEASES OF THE NERVOUS SYSTEM. 987 

osis can be tried in the use of sweat baths ; this may be distinctly 
helpful. 

Electricity is never of service, and tenotomy, though recommended 
by some, has no rational application. 

The spinal extension and nerve vibration should be used in these 
cases, where possible. The same method of application as recom- 
mended for ataxy is best adapted. 



HEREDITARY ATAXY. 

(Friedreich's Disease, Hereditary Ataxic Paralysis.) 

A form of combined lateral and posterior sclerosis, differing from 
the ordinary types of ataxic paraplegia and tabes by reason of the 
early age at which it begins, and certain additional symptoms. 
4 * Friedreich's disease " should give place to the better term I have 
used, although credit is due to Friedreich for the first classical descrip- 
tion. The heredity of the disease is rather of family tendency than 
of direct descent, for in most cases a neuropathic temperament can 
be traced, but as a rule it affects several members of the same gen- 
eration. Owing to this fact, some pathologists have tried to estab- 
lish the theory of an arrest of development in the spinal cord, though 
the best authorities (see Gowers) do not in every case admit this, 
insisting on interpreting it as a genuine sclerosis. 

Other causes than heredity and neuropathic tendency play a minor 
part. Alcoholism in the parent, syphilis, consanguinity of father 
and mother, if not causing, may at least intensify the disease. The 
sexes suffer equally, and the age most marked is the seventh and 
eighth years of life. It may be earlier or even later. 

Symptoms* — The first sign is a gradual loss of coordination, 
beginning in the legs, with a peculiar gait, more swaying, reeling 
like a drunken man, instead of the high-stepping, stamping gait of 
true tabes. Romberg's sign cannot always be trusted. In children 
the first indication may be a readiness to stumble and fall as the dis- 
ease advances ; the arms, and even the heart, are clearly involved, and 
their movements are swaying, jerky, and choreiform. The muscles 
do not lose their power and the nutrition is good, but the reflex action 
is lost. Rarely it is retained or increased. Speech is finally impaired ; 



988 THE PRACTICE OF MEDICINE. 

it is slow and the expression dull, but the mind may not lose its vigor 
till the very end. Nystagmus should always be looked for as it is an 
important sign, but atrophic optic neuritis is seldom found. Though 
nutritional perversions are not present, there is paralysis, and some 
of the most common changes are deformities, due either to the mus- 
cular lesions or to mechanical irregularities. Sensory symptoms are 
variable, though rarely are there any lightning pains or severe pains 
of any character. There are no visceral crises. The duration of 
the disease and the rate of progress also are uncertain, death being 
generally due to some intercurrent disease. 

Pathological Anatomy. — This is a sclerosis of the lateral, extend- 
ing sometimes into the anterior columns, with an intensity of the pro- 
cess in the posterior columns (as in tabes) more marked than in ataxic 
paraplegia. 

Diagnosis. — Hereditary ataxy (Friedreich's disease) is distin- 
guished from tabes by the fact that it begins usually in very young 
children, younger always than those in whom pure tabes can be dem- 
onstrated, and by the absence of " lightning pains " and crises or 
other pronounced disturbances of sensation. Disseminated sclerosis 
does not begin so early, nor does it appear grouped in families, and 
disorder of speech is different, while there is a more marked tendency 
to convulsions. Nystagmus in children must always suggest hered- 
itary ataxy. Chorea should always be carefully excluded. 

A disease of congenital origin, or one implying a congenital defect 
in function, holds little encouragement for treatment. 

The methods employed against ordinary tabes, such as arsenic* 
silver, and perhaps phosphorus, may be tried, and any symptomatic 
measure thought advisable ; but it is a question what good, if any,, 
can be obtained from mere drug exhibition. 



PELLAGRA. 

Fortunately the disease does not appear in America, but is en- 
demic and even hereditary among the poorer classes of Italy, Spain,, 
and Southern France, whose diet consists largely of the native maize, 
a fungus (or as some claim a perverted growth) of which is the cause* 

The name is significant only of one phase of the disease, the affec- 
tion of the skin, but in a severe grade there can be little doubt that 



DISEASES OF THE NERVOUS SYSTEM. 989 

the spinal cord, in its lateral and posterior columns, with some atro- 
phy of the nerve cells in the anterior cornua, is affected. 

The first attack begins with symptoms of a mild sun-stroke, with 
an erythematous eruption on the skin to which it has been likened, 
malaise, vomiting, and fever ; recovery may be complete from this, 
but in subsequent attacks, especially if the unhealthy maize has not 
been excluded from the diet, in addition to the fever and other con- 
stitutional and digestive trouble, there are symptoms pointing to 
involvement of the spinal cord resembling ataxic paraplegia ; weak- 
ness in the legs, increased muscular irritability even to spasm, inco- 
ordination with tremor. 

There can be an acute course with symptoms of spinal meningitis, 
or a chronic course, leading to paraplegia, dementia, and death from 
exhaustion. The reader who is interested in the poisonous effects of 
the various grains and allied products on the nervous system will 
find fuller reference to such diseases as pellagra, ergotism, lathy- 
rism, in monographs on the subject referred to by text-books going 
more minutely into diseases of the nervous system. 



PROGRESSIVE SPINAL MUSCULAR ATROPHY. 

{Amyotrophic Lateral Sclerosis [Charcot], Chronic Polio - myelitis, 

Wasting Palsy.) 

We now come to the third great division of the chronic diseases 
of the spinal cord, where the sclerosis is never detected in the pos- 
terior columns, seldom in the lateral columns, and is most marked 
either in the anterior horns, the form labeled by Gowers as atonic 
atrophy, or in the motor (pyramidal) tracts with added involvement 
of the anterior horns, the form of tonic atrophy (Gowers), or of amyo- 
trophic lateral sclerosis (Charcot). These types may be clear and 
distinct in their development, or there may be all stages of gradation 
from one to another, so that it is certainly best to consider them as 
only one disease with different manifestations, following in this the 
good example of Leyden and Gowers. 

Pathology. — Opinions as to essential pathology I must leave to 
technical studies on the subject ; I may as well, however, put down 
here all that is necessary for the student to know of the facts. The 
muscles shrink away and undergo fatty degeneration, while the per- 



990 THE PRACTICE OF MEDICINE. 

ipheral nerve roots (motor) degenerate. The anterior nerve roots, 
related to the affected muscles, atrophy ; but the most marked changes 
are found in the anterior horns. Here we see atrophy, granular pig- 
mentation, and disappearance of the ganglion cells. The blood-ves- 
sels may be increased in size, and in advanced cases the whole ante- 
rior horn is shrunken and the ganglion cells disappear. * The grad- 
ual disease and disappearance of the ganglion cells explain the grad- 
ual atrophy of the muscles, as the former control the nutrition of the 
latter. In the tonic atrophic form (amyotrophic lateral sclerosis) 
there is found in addition to these changes a decided sclerosis of the 
anterior lateral tracts, generally most intense in the cervical region, 
as the arms are most always the parts first involved. It is beyond 
dispute that the wasting of the muscles depends upon the disease of 
the grey matter, and particularly that of the ganglion cells and the 
fibres proceeding from them. A slow decay of the motor path, in which 
the lesion of the ganglion cells is a striking incident, and the element 
on which the nutrition of the muscles depends, a wasting that is sec- 
ondary to the spinal atrophy, is perhaps the best way of considering 
the lesion as a whole. 

Symptoms. — Progressive muscular atrophy begins usually in the 
upper extremities, though the legs may be simultaneously, or very 
soon afterwards, involved. Preceding the wasting, which is the symp- 
tom objectively most important, there may be some mild pain in the 
parts to be immediately affected. This wasting, above mentioned, 
and weakness usually come on together. Either single muscles or 
groups of muscles, or whole systems of muscles waste away. Paraly- 
sis comes on as the muscles waste. On the hand, for instance, depres- 
sions may be seen between the metacarpal bone, and between the ten- 
dons of the palms, and the hand loses its strength. Occasionally the 
arm suffers first, and then the flexors are seen to disappear or the 
biceps and deltoid may lose their roundness. Then the arm hangs to 
the side, the hands look thin and withered, and the power is gone. 
If the muscles of the back are not first involved, they soon follow, 
in which case the trapezius, especially the lower part, may show a 
disposition to atrophy. When the muscles of the neck suffer, the 
head assumes a peculiar attitude ; it is habitually inclined backward 
so as to balance on the spine, but if this balance is lost, the chin 
drops forward onto the chest, and the head can then be brought for- 



DISEASES OF THE NERVOUS SYSTEM. 991 

ward only when the patient throws the trunk back, so as to be able 
to give a sudden jerk by which the head, as the sterno-mostoids con- 
tracts, returns to its original position. In this connection must be 
noted that the platysma myoides is never wasted, and is often, on the 
contrary, hypertrophied. The respiratory muscles suffer, and as they 
lose their size and vigor life may be threatened by difficult respira- 
tion. If the diaphragm is involved the breathing is carried on by 
the intercostals, or if the diaphragm escapes and the intercostals 
weaken, breathing is then abdominal. A careful examination is often 
necessary to prevent the error of supposing that a compensatory over- 
action of one set or the other shows no involvement of either dia- 
phragm or intercostals. Wasting in the legs is not so common as in 
the arms, though it may occur. The face generally escapes, and 
shows a contrast to other parts of the body. Advanced stages of the 
disease shows a wasting that leaves nothing but skin and bone, the 
" living skeletons " of a circus or museum. 

The spine generally shows some curvature. As the disease ad- 
vances, electrical excitability diminishes, till none at all can be found ; 
but the muscular irritability itself is retained, so that fibrillary con- 
tractions are common, either spontaneous or induced, although the 
reflex action ("knee-jerk") gradually disappears, except in the cases 
of " tonic atrophy " where the muscles get stiff, and do not waste 
completely ; here the knee-jerk is retained. 

Sensory symptoms are slight, only some pain or numbness. The 
atrophied limbs are cold and the skin livid. The bladder and rec- 
tum retain their functions, and the iris and optic nerve never suffer. 
The three distinct manifestations of the disease are, according to 
Gowers: (1) Atonic atrophy, becoming extreme. (2) Muscular 
weakness with spasm, but without any wasting, or wasting only very 
slight in degree. (3) Tonic atrophy, rarely extreme in degree, with 
myotatic excess. Other spinal cord sclerosis may occur intercur- 
rently, and tabes has been associated with progressive muscular atro- 
phy. Bulbar paralysis, to be described later on, is either a mani- 
festation of the disease, or independent, with analogous pathological 
changes in the pons and medulla. 

Progressive muscular atrophy, as the name implies, is steadily 
progressive, but not necessarily at the same rate. If it becomes sta- 
tionary as the result of treatment or otherwise, it is apt to stay so, 



992 THE PRACTICE OF MEDICINE. 

but unfortunately a tendency in this direction may manifest itself 
only at a late stage. Two or three years is the ordinary interval 
before a limb becomes helpless, though a sudden increase in the 
severity of all symptoms is not rare. The greatest danger lies in 
the interference with respiration, and bulbar symptoms. 



BULBAR PARALYSIS. 

(Glosso-Labio - Laryngeal Paralysis.) 

Duchenne has given his name to this disease, the symptoms of 
which may be primary, or secondary, as a degenerative disease of 
the nuclei of the motor path, analogous to the lesions mentioned in 
progressive muscular atrophy, with which it is often associated. That 
it does appear primarily is the reason for giving it a separate de- 
scription. 

The acute form is either (a) hemorrhagic or embolic, or (b) 
inflammatory. When the onset is sudden (apoplectiform) the symp- 
toms are generally bilateral. Speech is soon lost, the muscles of the 
tongue and lips being involved, with a consequent escape of saliva, 
swallowing is difficult, the lips are flabby, and perhaps the larynx 
suffers. Sometimes there is associated with the face and larynx 
symptoms a hemiplegia in the leg or arm, or an alternating hemi- 
plegia, one side of the face and the other side of the body being 
paralyzed. 

If the case does not prove immediately fatal, it may turn into 
the chronic form, which begins after the fortieth year, as a part only 
of general motor-nuclei degeneration. Here is noticed at first only 
a difficulty in speech ; the tongue is partially paralyzed, and its mus- 
cles may atrophy ; tremor appears ; saliva accumulates in the mouth 
and may escape from it, chewing and swallowing are difficult, and 
the food is apt to regurgitate. The muscles of the vocal cord waste, 
and the voice is feeble, though seldom is there an actual paralysis. 
The mind remains clear, and death, which comes early, comes by 
aspiration pneumonia, or choking, or more rarely from paralysis of 
the muscles of respiration. 

The Peroneal Type of Muscular Atrophy. — This is the designa- 
tion used for a condition described by Dr. Howard Tooth, of Lon- 
don, wherein the symptoms seem confined to the peroneal muscles, 



DISEASES OF THE NERVOUS SYSTEM. 993 

and a course apparently analogous to that of progressive muscular 
atrophy. It begins in both lower extremities simultaneously as a 
progressive weakness and paresis ; the muscles waste slowly, individ- 
ual muscles, rather than groups, suffering. Club-foot is a frequent 
result of this unequal distribution of muscular atrophy. The arms 
suffer much later and then the claw-hand results. The affected mus- 
cles occasionally present slight fibrillation. Faradic irritation may 
become extinct, and there may be partial or complete reaction of de- 
generation. There are no sensory, rectal, or vesicle symptoms, and 
though the knee-jerk is usually diminished, it is not necessarily lost. 
There is an undoubted heredity, and seldom does the disease show 
itself after the twentieth year. The progress is slow and sure, and 
the prognosis gloomy. The pathology is indistinct, as spinal cord 
lesions are not demonstrable in every case, but there seems a certain 
tendency to trace the disease to a primary neuritis with secondary 
involvement of the cord. 

Treatment. — Keep the general health as nearly normal as possi- 
ble, and encourage exercise without the extreme of fatigue. Gowers 
claims that strychnine has proved a powerful check to the progress 
of progressive muscular atrophy, used hypodermatically, in daily 
doses at one time of the nitrate, beginning at one-hundredth and 
increasing up to the one-fortieth of a grain. The effects must be 
carefully watched. He adds that strychnine by the mouth rarely 
accomplishes anything. Electricity is useless. Massage is a ration- 
ally proper means of treatment, but must be sedulously persevered 
in. In fact, an incurable disease like this needs the greatest hope 
to counteract the ceaseless discouragement the patient's condition pro- 
gressively presents to the physician and the world. Rely on nothing, 
try everything, but make no promises. Lachesis, causticum, hyos- 
cyamus, gelsemium, and arnica are well worth a trial. 



PSEUDO- HYPERTROPHIC MUSCULAR PARALYSIS. 

(Muscular Pseudo-Hypertrophy. Hereditary or Juvenile 
Form of Muscular Atrophy.) 

Besides the spinal form of muscular atrophy there is a condition 
of the muscles in which they waste, though there is for a time an 
increased deposit of fat to take the place of the disappearing muscle 

63 



994 THE PRACTICE OF MEDICINE. 

tissue ; but this disease is not dependent on any spinal or nervous 
affection, and ought, therefore, to be classified among diseases of the 
muscles properly ; but it has been historically so often treated among 
diseases of the nervous system, and is clinically so closely allied to 
Progressive Muscular Atrophy, that as a matter of fact its discussion 
seems to fall in here better than anywhere else. It begins during 
the developmental period of childhood, and depends on some devel- 
opmental tendency, inherited, perhaps, but manifesting itself rather 
in family groups than in one generation after another. Observation 
seems to show that the maternal influence is greater than the pater- 
nal, as children of the same mother by different fathers have suffered. 

Males are affected much more than females ; and the symptoms 
never occur after full maturity, generally speaking, before the tenth 
year. 

Pathology. — At the beginning it is wise to caution the student 
against a too great refinement in distinguishing " types " of this dis- 
ease. Erb (1884) describes a " Juvenile Form of Muscular Atro- 
phy." Leyden has another, Landouzy and Dejerine a third. All are 
but various manifestations of the same process, and the diagnosis 
should be made without regard to " types," though no harm is done 
by particularizing as to the peculiarities in each case. 

The motor nerves are normal, as is also the spinal cord. The mus- 
cles are seldom larger, and as a rule smaller than natural ; they are 
pale, and look like masses of adipose tissue ; even under the micro- 
scope this appearance holds good. The resemblance to a fatty tumor 
is pronounced except that here and there are found tracts of connect- 
ive tissue and muscular fibre. Evidently the disease is not due to 
any lesion of the spinal cord ; it is a primary disease of the muscles, 
an over-growth of interstitial connective tissue, with or without a 
deposit of fat, with a secondary wasting of muscular fibres. It is a 
congenital defect which limits and destroys muscle growth, and it 
is the deposition of fat that causes the (apparent) enlargement of 
the muscle. 

Symptoms. — Impairment of muscular power is first noticed as 
gradually increasing, without any decided or definite cause. Healthy 
children attract the parents' attention by awkwardness in walking, 
jumping, and especially in going up-stairs, and in fact such manifest- 
ation is a good diagnostic sign in distinguishing between pseudo- 



DISEASES OF THE NERVOUS SYSTEM. 995 

hypertrophy and spinal muscular paralysis. As a rule the former 
begins in the muscles of the legs, thighs, rump, and back. The gait 
becomes progressively harder, wabbling, the abdomen bulges forward, 
and there is even a lordosis. Most characteristic is the child's attempt 
to raise itself from the floor. As the gluteal muscles loose power, 
the child rests on all four extremities, straightening its legs, rests 
one hand on the corresponding knee, and then by a balance and a 
final jerk throws the upper part of the body into equilibrium. At first 
no change in size is apparent, but gradually the muscles appear large, 
either universally or in groups : the calf muscles are first affected, 
sometimes attaining a remarkable size, then the recti, the glutei, and 
the infraspinati. This enlargement (pseudo-hypertrophy, lipoma- 
tous) remains stationary, or decreases, till there is an actual atrophy 
as to both muscle-fibre and size. The hand and arm suffer little or 
escape altogether. 

These diseased muscles are weak, not necessarily in proportion to 
change in size, though the atrophying muscles are weaker than those 
hypertrophy in g. 

Electrical reaction is diminished, but never do we find the typical 
reaction of degeneration. Sensibility is normal, and the sphincters 
are not impaired. The tendon reflex is gradually lost, as might be 
supposed from its dependence on proper muscular nourishment and 
tone. The skin is apt to take on (Struempell) a peculiar marble 
blue color. Mental symptoms are uncommon. As the disease pro- 
gresses, contractions (talipes equinas) and spinal curvatures occur. 
The rate of progress is generally slow, and the patient may lie bed- 
ridden for years, till some intercurrent affection or the failure of the 
respiratory muscles ends the scene. 

Diagnosis. — This is not difficult if we remember that pseudo- 
hypertrophy begins in youth (childhood), as a congenital (heredi- 
tary ?) affection ; that as a rule the leg and rump muscles are first 
attacked ; that there is no reaction of degeneration or the noticeable 
muscular fibrillary twitching. The peculiar gait and mode of ris- 
ing should be emphasized. 

Treatment. — Symptomatic treatment may be tried and persevered 
in, but none can be depended on, for the best nervines, as phosphorus, 
arsenic, strychnine, etc., have been found untrustworthy. Undoubt- 
edly the best rational treatment lies in an attempt to foster strength 



996 THE PRACTICE OF MEDICINE. 

and restore the muscular nourishment by exercise, electricity, com- 
bined with vigorous massage and passive motion. Tenotomy has 
given good results in securing greater stability in the upright posture. 



SYRINGO MYELIA. 

A disease of the spinal cord, characterized by the formation of 
cavities within the cord, associated with symptoms of amyotrophic 
paralysis, with loss of heat and pain sensations, but with retained 
perceptions of touch. 

This must not be confounded with dilatation of the spinal canal, 
for that is normal, or at least only semi-pathological, being either 
congenital or due to pressure. The cavity in syringo myelia, on the 
other hand, is irregular in shape, situated generally in the posterior 
portion of the cord, but spreading to the central portion as it increases. 
This cavity is caused by the formation within the cord of a tumor of 
the gliomatous variety, a gliosis, most possibly congenital, and brought 
into active life by shock, disease, or trauma. 

Symptoms. — These are variable and begin gradually; as the 
gliosis is most apt to be in the cervical region, the arms are usually 
first affected ; there is then weakness in the hands and arms, numb- 
ness, then muscular atrophy in one or both hands, quite widespread 
loss of sensibility to pain and heat, which may be unknown to the 
patient till examination reveals the fact. Tactile and muscular sense 
are impaired. 

Th^ motor symptoms usually come on after the sensory loss, shown 
by extreme weakness, but seldom paralysis ; unsteadiness of move- 
ment. Reflexes are normal, or increased or decreased. Trophic dis- 
turbances are not uncommon, as there may be herpes or eczema, or 
*' glossy skin," or a dry hard skin, with little sweat. Circulation is 
poor, and the bones may be brittle. 

Diagnosis. — Signs of amyotrophic paralysis with muscular atro- 
phy and loss of sensations of heat and pain, with retention of sensa- 
tion of touch, brings a typical case within the bounds of recognition. 

Prognosis is grave, but the disease may wear on for years. 

Treatment. — Unfortunately the diagnosis can seldom be made 
till the disease is well advanced, but even then little can be done to 



DISEASES OF THE NERVOUS SYSTEM. 997 

treat the actual condition. Care may prevent bed-sores and stiffness 
of joints, and cocaine may be used for the pains ; other symptoms 
must be met as they arise. 

In this connection mere mention must be made of a remarkable 
affection first noticed by Morvan in Brittany, and called by his 
name. Apparently it is analogous to syringo myelia, with an asso- 
ciated peripheral neuritis. Besides many of the symptoms of that 
disease, there is a peculiar trophic change called by Morvan " pain- 
less whitlows," which destroys the nails ; the skin cracks, and has a 
peculiar livid color. A careful discrimination must be made between 
this and leprosy. 

TUMORS OF THE SPINAL CORD. 

I need only say here that syphilis, tubercle, and trauma are the 
most common causes of tumors. In some few cases, parasites have 
lodged within or on the membrane. Sometimes congenital abnor- 
mal growths are found. The tumor may show itself in a syringo 
myelia (q. v.) ; or it may give external evidence of its existence ; or 
it may lead to a pressure myelitis. Pain, gradually increasing par- 
alysis, paraplegia, muscular spasm, loss of sensation, and impairment 
of nutrition, are the most common symptoms. The diagnosis depends 
so much upon an exact study of the anatomy and physiology of the 
cord, and the treatment, unless in cases resembling transverse mye- 
litis, is so much a matter of guess-work or of the knife that I shall 
not stop to discuss it here. The reader can get valuable information 
from the bibliography. 

SPINA BIFIDA. 

A congenital fissure of the lower end of the spinal column, com- 
bined with a hernial protrusion of the dural sack. This seldom 
interferes with the birth of the child, though the tumor may be evi- 
dent, and it is only later on that trouble may be anticipated. The 
sack is usually filled with cerebro-spinal fluid, and the skin over it 
is generally red and stretched. If the canal is widened at the same 
time it is designated as a hydromyelia ; pressure on the sack may drive 
the fluid back into the spinal canal, which shows itself at the fon- 



998 THE PRACTICE OF MEDICINE. 

tanelles, and by heightened brain pressure, convulsion, or slow pulse. 

If these symptoms are not brought out, the conclusion is justi- 
fiable that the tumor is independent of the cord. 

The tumor is apt to grow, and parri passu are symptoms of par- 
alysis, anaesthesia, bladder disturbances, etc. If the sack burst, we 
may expect a purulent meningitis. The treatment belongs to the 
surgeon, but he is by no means always successful. 



NERVE VIBRATION. 

[The method of cure of nervous diseases, called nerve percussion 
or nerve vibration, has become an important part of the therapeutic 
resources of neurologists. That the reader might become acquainted 
with this method and its application I asked my friend, Dr. N. B. 
Delamater, Professor of Mental and Nervous Diseases, to write out 
his experience with this agent — which he has kindly done in the fol- 
lowing article.] 

Nerve vibration, as a therapeutic measure, was first proposed by 
J. Mortimer Granville, of London, about 1876. Since then experi- 
ments have been made and a few articles published, from time to 
time, by others ; probably the most prominent article is by Dr. M. 
Boudet de Paris. My attention was called to the subject in 1883, 
by J. Mortimer Granville's brochure on the subject published that 
year. Procuring a percuta from London, I at once commenced a 
line of experimental work, and have established to my own entire sat- 
isfaction that it is a valuable therapeutic agent. 

Dr. Granville's claims are based on the scientific principle that 
all, or nearly all, manifestations of force in nature are the result of 
vibrations of molecules, or atoms, in the atmosphere. From his book 
I glean the following arguments and conclusions. 

" Nerve action or activity consists in, or is accompanied by, vibra- 
tions of essential elements of nervous tissue. 

Cells vibrate as bodies suspended in the intercellular stroma of 
the grey matter, and fibres vibrate as delicately poised rods or strung 
cords within the partite cylinders formed by internal prolongations 
of the neurilemma or nerve sheath." 

Febrile or other deposits within the nerve sheath, occurring in 



DISEASES OF THE NERVOUS SYSTEM. 999 

the course of disease, or proliferation of the connective tissue, must 
necessarily interfere mechanically with or entirely interrupt the pos- 
sibility of vibration. 

The solidification called sclerosis causing loss of sensation or power 
may be an accompaniment or a result of primary atrophy of nerve 
cell and fibre ; in this case proper exercise would increase the nutri- 
tion and stimulate the activity of cells and fibres. The almost uni- 
versal law of organic matter is, that it feeds as it acts and only in 
proportion to its activity. By inducing and maintaining vibratile 
motion, the encroachment of solidifying deposits or of proliferation 
of tissue may be arrested, and in addition absorption be promoted. 
The essential indication in this class of cases then would be restora- 
tion and promotion of mobility of the vibratile elements. There is 
no way in which this can be accomplished so well as by the applica- 
tion of mechanical vibration. 

Electricity in various forms has been suggested to accomplish 
this result, but has not and obviously cannot accomplish the full 
results desired. Static electricity does not traverse nerve tissue, does 
not produce or maintain regular continuous vibration in the tissue 
over which it spreads. 

The Galvanic current is a form of vibration or motion closely allied 
to that of nerve force, but it travels over rather than through the 
nerve trunk, and produces phenomena of motion or sensation more 
by its own action than by setting in operation the natural nerve force 
or motion. 

The Faradic current does produce mechanical vibration much 
more marked than either of the other forms, and while in many of 
the cases, in which we believe mechanical vibration is beneficial, it 
has given good results, yet it has not accomplished all that was 
expected of it. The reason being, probably, that with the mechan- 
ical vibration is an added force, which in a measure does, in itself, 
what we want to compel the nerve to do. In addition the constant 
change in direction of the current produces an inharmony of rhythm 
or vibration, while harmony is the one thing that must be obtained 
to insure healthy nerve activity. By simple mechanical vibration 
we compel the nerve to act of itself and in the natural physiological 
way. 

I quote these propositions as given by Dr. Granville : 



1000 



THE PRACTICE OF MEDICINE. 



" First. — When nervous tissue acts, its essential elements, viz., 
cells and fibres, vibrate. It follows that by throwing these elements 
into vibration by mechanical movements, we establish a condition 
favorable to the discharge of nervous force from the centre affected, 
and at the same time stimulate the nerve centre, when discharged, 
to develop new force to compensate the loss of energy expended in 
exercise. 

J\ BS353I 




THE PERCUTA WORKED BY ELECTRO-MAGNETISM. 
Fig. 1 E, screws connecting battery wires with the percuta. A, screws for mak- 
ing connection. There are two; either may be used. That nearest the hinge 
of the vibrator causes the hammer to beat at the highest speed. C, brass 
cylinder, through which the rod of the hammer passes. D, vulcanite tube, 
which is attached with a screw, and regulates the length of the stroke made 
by the hammer. F, button which, being pressed or pushed with the finger, 
sets the percuta going. 

Second. — The vibration of nervous elements being a purely me- 
chanical process, it must be comformable to the laws or conditions 
that govern the vibratile movements of other bodies, whether organic 
or inorganic — as reed instruments, — and vibrations of cells and 
fibres should therefore be amenable to the laws of concord and dis- 



DISEASES OF THE NERVOUS SYSTEM. 



1001 



cord. In short, what Newton discovered and taught in explanation 
of the phenomena of light and sound, with the recognized correla- 
tion of the diatonic and chromatic scales, must be equally applicable 
to an as yet unrecognized but doubtless existing scale of nerve vibra- 
tion, and such affinity must exist between the nature of vibrations, 
whether in afferent, sensory, or efferent, motor nerves. These effects 
are capable of demonstration, producing changes in the rate and 
rhythm of nerve vibrations precisely correspondent with those which 
would be effected in the vibrations of unorganized substances, by the 
operation of the same or similar agents working in like process. 




c U LJ H 
D D 

Fig. 2 — 1, bent hammer; 2, large disk, for use in water; 3, small disk; 4> hard 
brush. This brush grew out of a suggestion made by Dr. Hugh Campbell, 
and is very effective; 5, light brush for relief of superficial pain and to red- 
den the surface; 6, pointed hammer; 7, flat-headed hammer. 6?, connection 
screw, tipped with platinum; D D, vulcanite tubes to protect hammers; H, 
screw to attach hammer to percuta; /, clamp to fix connecting screws. 

Dr. Henry F. Gary, of Baltimore, has applied this theory to the 
treatment of deafness dependent on abnormal deposits, or prolifera- 
tion of tissue, interfering with the power of motion in the hearing 
mechanism. Clinical experience reported by a large number of 
aurists has fully demonstrated that it is possible to induce absorption 
of inflammatory deposits or proliferated tissue by pure mechanical 



1002 THE PRACTICE OF MEDICINE. 

vibration, the restoration of function following as a natural sequence. 

Thus we see that when vibrations of normal rhythm and frequency 
are conveyed and imparted to the auditory nerve, and only then, it 
performs its functions properly. 

Since 1883 I have experimented with mechanical vibration of 
nerve and feel confident that it now deserves a prominent place among 
therapeutic measures. My use of it has been confined in the main 
to cases of sclerosis of the cord and to such other organic and func- 
tional neuroses as are not usually considered amenable to other 
known methods of treatment. 

I first used the percuta of Dr. Granville made in London ; later 
I was able to get as good results, with a less cumbersome instru- 
ment, by having an electrical dental hammer fitted with suitable 
points. 

For application to the ear the vibrometer of Dr. Gary is, I think, 
in quite general use among aurists. In it an attempt has been made, 
and with some degree of success, to tune the instrument to a correct 
number of vibrations per second, to suit individual cases, but no sat- 
isfactory data for or method of tuning has been evolved except for 
the ear. 

Special directions for some of the more important diseases will 
be found in the articles on them. There is an objection to this line 
of treatment that I fear will be very potent in the future, as it has 
been in the past — the time and close attention required in order to 
produce desired results. The treatment must be given daily, with 
great care as to uniformity of pressure, order, and time. 

The operator should commence at the same point and follow from 
point to point in the same order at each sitting. He should note 
accurately the length of time the hammer is held at each point, and 
make it uniform each day. It is better that treatment should be 
given as near as may be at the same hour. In using nerve vibration 
for the cure of neuralgia, the hammer should be placed over a spe- 
cially sensitive spot, if there be one, or over the point where the 
affected nerve lies nearest the surface ; at first it is quite likely to 
very materially increase the pain ; it is to be held firmly and steadily, 
and in a minute or two the pain may abate. It is my experience 
that the best results are obtained by stopping the application just as 
soon as fully satisfied of amelioration. I have seen many very sat- 



DISEASES OF THE NERVOUS SYSTEM. 1003 

isfactory results in long-standing cases that I had failed to reach by- 
other means. 

In spasmodic motor cases I have used this treatment very little, 
as I have usually found other means, requiring less of my time and 
less expensive to the patient, efficient. Several European physicians, 
however, report very favorably on its use in chorea and other dis- 
orders in which irregular motor spasm, either local or general, is a 
prominent feature. 

In these cases, if application be made while irregular and invol- 
untary motion is present, there is likely at first to be an exaggeration 
of the motion, followed by a subsidence and in a short time entire ces- 
sation of the motion. If application is at the time of quiescence, 
there is likely to be at first some spasmodic actions, followed very soon 
by quiet. In all cases, except for immediate relief of an evanescent 
disorder, the application should be regular and daily. 

I have never used it for the relief of constipation, although Dr. 
Granville has cured a number of stubborn cases. I have had some 
brilliant results in cases of evanescent functional paralysis. Also in 
several cases of spinal exhaustion, two or three of them accompanied 
by sexual weakness. The percuta or nerve vibrator may be run by 
electricity or by clock-work. 



CHAPTER X. 
INTESTINAL PARASITES, 



ASCARIS LUMBRICOIDES. 

"The long round worm, often called lumbricus, is a large nema- 
toid worm of a yellowish red color. The female is fifteen inches, 
and the male ten inches in length. The body is cylindrical, taper- 
ing to either extremity, but more rapidly towards the head. The 
mouth is triangular, having three lips. It is armed with numerous 
(about two hundred) microscopical teeth. The alimentary canal is 
simple, without division between stomach and intestine. The tail 
is conical and pointed. In the male it is curved like a hook towards 
the ventral aspect of the body ; in the female it is straight. The 
eggs, which are excessively numerous in each female specimen, are 
oval in shape, and have a thick, firm, elastic, brownish shell, which 
is usually nodulated on the surface. In these ova the embryos 
develop very slowly, for Davinne kept some alive for five years with- 
out perceiving any attempt of the immature tenants to escape from 
the shell. These embryos have a curious tenacity of life, for they 
cannot be destroyed by frost or complete desiccation. It has been 
doubted whether the eggs can be hatched, and the embryos escape 
and pass through their developmental stages to maturity in the ali- 
mentary canal of the subject infested by them. It appears, however, 
from the researches of Heller that this is possible. The lumbricus 
inhabits the smaller bowel, but is migratory in its habits, and has a 
peculiar tendency to wander. The worms have been consequently 
found after death in very curious places. They have been seen in 
the nasal passages, in the larynx and bronchi, in the ducts of the 
liver and pancreas, in the gall-bladder, and even in the cavity of the 
peritoneum, and in the interior of abscesses communicating with the 
abdomen. The worm has no power of penetrating the living tissues, 
but can pass through an ulcerating lesion of the vermiform appendix* 



INTESTINAL PARASITES. 1005 

and set up peritonitis by entering the cavity of the abdomen." (Eus- 
tace Smith, "Diseases of Children.") 

The ova of the lumbricus appear to be imported through the 
medium of impure water. This parasite is said to be especially com- 
mon in low-lying, marshy districts. 

Symptoms. — " The lumbricus, on account of its large size and its 
habits of nocturnal activity, is a cause of considerable irritation. 
This worm is said frequently to give rise to nervous disorders in the 
child ; and cases have been recorded in which severe headache, pho- 
tophobia, choreic movements, convulsions, and even profound coma 
have ceased on the expulsion of a number of these creatures. It 
is difficult to say what share the worms take in the production of 
such symptoms. Probably some additional cause is in operation, for 
in rickety children, whose tendency to convulsions and other forms 
of nervous disturbances is one of the most characteristic consequences 
of that phase of general malnutrition, I have not noticed that the 
presence of the long round-worm is especially liable to be accom- 
panied by eclamptic seizures. Probably in most cases where nervous 
symptoms are associated with intestinal worms the nervous disturb- 
ance is quite independent of any irritation produced by the worms 
in the bowels. It is common enough for children who are suffer- 
ing from undoubted disease of the nervous centres to be infested 
with lumbrici. Thus, in cases of tubercular meningitis, one or more 
long worms are often expelled by the action of aperients ; but it is 
needless to say that in such a case no amelioration in the symptoms 
follows the expulsion of the parasites. So, also, children under my 
care suffering from chorea have passed lumbrici, but I cannot call to 
mind a single case where any improvement in the disease has directly 
followed the appearance of the worm in the stools. If, however, 
the nervous symptoms supposed to be produced by lumbrici must be 
looked upon as somewhat problematical, there are other phenomena 
which can be referred with much greater certainty to the irritation 
set up by the entozoa. Severe abdominal pains of a colicky char- 
acter are not uncommon in children who suffer from these creatures ; 
and looseness of the bowels, occurring chiefly at night, is occasion- 
ally produced by this agency. I have seen several cases of this kind 
where a diarrhoea, after persisting for months, ceased immediately 
that the worm was got rid of." 



1006 THE PRACTICE OF MEDICINE, 

" A little boy, aged four years and a half, was said to have been 
troubled for three months with persistent looseness of the bowels. 
The purging was never very severe, but always worse at night. The 
motions were said to be very slimy, and after a dose of oil, usually 
contained thread-worms. The child often complained of colicky pain 
and tenesmus. He had been slowly wasting from the time the purg- 
ing first began. The occurrence of nocturnal looseness of the bowels, 
combined with the appearance of the tongue, which was very flabby, 
slimy, and drab-colored, with large fungi form papillae at the sides 
of the dorsum, made me suspect the presence of a long worm. I 
ordered a powder, containing one grain and a half of santonine and 
a half grain of calomel, to be given every night for three nights, and 
to be followed each morning by a dose of castor oil. After the first 
powder the child passed a long worm, and the diarrhoea ceased from 
that time. He then rapidly regained flesh." (Eustace Smith, " Dis- 
eases of Children.") 

As a rule, lumbrici become active at night, and may pass upwards 
into the stomach, or downwards into the colon and rectum. They 
have been known to issue spontaneously from the mouth of a child 
during sleep, or to appear from the bowel without being discharged 
in a stool. Their presence in the stomach may give rise to nausea 
and retching. Sometimes they pass into the common bile-duct and 
cause jaundice, by obstructing its channel. If jaundice rapidly 
develops in a child who is known to be troubled with this parasite, we 
should think of the possibility of this rare accident having happened. 
Sudden dyspnoea has been known to arise. In some instances, at 
least, this has been discovered to be due to the actual penetration of 
the worm into the air-passages. Thus, Andral has known death to 
occur from this cause ; and Arronsshon has reported the case of a 
little girl, aged eight years, who, after suffering for two hours from 
distressing dyspnoea and cough, suddenly, after a violent paroxysm 
of cough, ejected a long worm and was immediately relieved. In 
other cases, the difficulty of breathing has been attributed to direct 
pressure upon the larynx and trachea by a number of worms in the 
gullet, or to reflex action, propagated from the intestines ; but these 
explanations are neither of them very satisfactory. It has been so 
much the tendency to attribute every kind of discomfort arising in 
cases where worms are present to the irritation of parasitic creatures 



INTESTINAL PARASITES. 1007 

in the bowels, that probably sufficient care has not always been taken 
to exclude other and less obvious causes of the symptoms. 

Lumbrici are sometimes present in very great quantities. The 
largest number I have known to occur together in one child has been 
twelve ; but they are sometimes much more numerous, and may even 
amount to several hundred. When thus multiplied, the worms may 
form bundles, which impede the passage of the contents of the bowels, 
and are said in some cases to give rise to the symptoms of obstruc- 
tion." (Eustace Smith, " Diseases of Children.") 

Treatment. — The treatment of worms by the radicals of our 
school excludes their expulsion ; a rule I cannot accede to, because 
when they accumulate in large numbers they may cause convulsions 
and other serious symptoms. In Hahnemann's preface to the path- 
ogenesis of cina he says : " For centuries this important drug has 
been used to expel worms, being given in doses of ten, twenty, thirty, 
and sixty grains. I shall say nothing of the dangerous and even 
fatal consequences attending the administration of such doses, and I 
would merely make the passing remark that a few worms in lively 
(healthy) children cannot be considered an important disease ; they 
are quite common in childhood, and cause but little inconvenience 
in an age when the psoric miasm is yet in a latent condition. On 
the contrary, however, when worms are found in large quantities 
they originate in a morbid condition of the system, in the psoric 
miasm which has been roused from its latent state, and which must 
be cured, otherwise the worms are speedily produced." 

He denounces the expulsion of worms, which seems to me very 
illogical. Why not expel them, and then remove the morbid state 
of the intestinal secretions? Psora, as Hahnemann taught, is but 
another name for anaemia, scrofula, and tuberculosis. Worms are 
generally present in these conditions. Remove these and the worms 
if expelled will not be reproduced. Guernsey (Obstetrics) men- 
tions thirty medicines for worms, because each possesses some symp- 
toms that may be caused by worms. Of these thirty, only calcarea, 
cina, silica, sulphur, and teucrium are of much value. To these I 
would add chenopodium, salicin, salicylate of soda, naphthalin, and 
carbonate of creosote, each given in one to five grains of the lx or 
even the crude drug, before or after meals, and if the child is con- 
stipated followed by colon flushing, or a mercurial laxative. If the 



1008 THE PRACTICE OF MEDICINE. 

patient is old enough to swallow a capsule, the following formula is 
very efficient : 

3^! Merc. dulc. gr. xx. 

Santonine gr. x. 

Papoid gr. xx. 

Fill ten capsules. Give one before each meal. 

For young infants make thirty powders of the above, and give 
one three times a day. 

OXYUKIS VERMICULARIS. 

" Description. — The small thread-worm, often called seat-worm, 
belongs to the order nematoda. To the naked eye these worms have 
the appearance of fine white threads. Both female and male speci- 
mens exist together, the former being the larger. In both sexes the 
anterior part of the body is of fusiform shape. It is narrowed towards 
the head, which is abruptly truncated, and provided with three tuber- 
cles. The male is one-sixth of an inch in length. Its intestinal tube 
extends the whole length of its body, and terminates in the anus 
at about the middle of the tail. The tail is arranged in a spiral 
form. The penis is minute and hook-shaped. The female measures 
nearly half an inch in length. Its body ends in a long tapering tail, 
which is three-pointed at the end. Under the microscope its uterine 
ducts can be seen to contain a multitude of ova. The eggs are long 
and unsymmetrical. They may be readily hatched by exposing them 
to the sun in a moistened paper envelope, as in the experiments of 
Vix and Leuckart. When this is done, tadpole-shaped embryos 
escape after five or six hours, and rapidly develop into slender worms. 
It appears from the researches of Leuckart and Heller that the 
embryos can escape from the ova in the human body. Heller states 
that their liberation takes place in the stomach under the influence 
of the gastric juice. From the stomach the creatures pass into the 
duodenum and upper bowel, growing rapidly as they descend the 
alimentary canal ; and by the time they reach the caecum have ar- 
rived at sexual maturity." 

Causation. — " The means by which thread-worms gain access to 
the human body is by the direct passage of the ova into the mouth. 
The eggs are often introduced clinging to fruit, cresses, and various 
articles of food. But they may also be directly conveyed to the 



INTESTINAL PARASITES. 1009 

mouth by the patient himself. It has been said that the embryo is 
liberated from the egg in the child's stomach by the action of the 
gastric juice upon the ovum. It has also been stated that each indi- 
vidual female worm contains in itself a multitude of eggs, which pass 
out in large quantities with the stools. The embryos are probably 
not liberated from the ova in the bowels ; but if the ova are reintro- 
duced into the alimentary canal by the mouth, they become exposed 
to the action of the gastric juice in the stomach, and their contents 
may be set free. According to Dr. Cobbold, children frequently 
carry the ova under their nails ; for the irritation to which the pres- 
ence of the oxyures gives rise obliges them to seek relief by scratch- 
ing. In this way the eggs may be transferred directly to the mouth. 

Symptoms. — " In the case of thread-worms, the patient seldom 
complains of abdominal pain, but the irritation set up in the rectum 
by the presence of the entozoa gives rise to a troublesome itching of 
the fundament, which in sensitive children may cause an extreme 
degree of suffering. This irritation comes on towards the evening, 
and at night may be so distressing that sleep is greatly interfered 
with. In some cases, in addition to the itching, shooting pains may 
be complained of in the same part. Catarrh of the rectum is not 
uncommon in such subjects. There may be looseness of the bowels, 
and the evacuations are often discharged with straining efforts. They 
may be followed by prolapse of the rectum. The stools often con- 
tain glairy mucus, and sometimes blood in streaks, or even clots of 
considerable size. Difficulty in emptying the bladder may be a con- 
sequence of the irritation, and the child sometimes holds his water 
for many hours together. Itching of the nose, a leaden tint of the 
lower eyelid, and swelling of the upper lip, are also very common 
symptoms when thread-worms are present." (Eustace Smith, " Dis- 
eases of Children.") 

In addition to the above, I will state that I have had several 
cases of leucorrhoea in children and women, which I discovered were 
caused by the presence of pin-worms in the vagina. There is no 
reason why they should not migrate into the uterus and bladder. 
Such cases I think have been reported. 

" In the course of a clinical lecture on ' Thread-worms in Chil- 
dren,' published in the i Clinical Journal,' Dr. Sansom said : 

" As regards treatment in the case of the hosts of oxyurides, the 

64 



1010 THE PRACTICE OF MEDICINE. 

indications are : (1) to expel the intruders and all their ova ; (2) 
to prevent the entry of ova into the alimentary tract. The total expul- 
sion o£ the parasites is no easy matter. It is important to keep up 
for several weeks a frequent aperient action ; castor oil, sulphate of 
magnesia, rhubarb, or other simple aperients, may be employed for 
this purpose. If the parasites present at the rectum, or if there be 
local symptoms hereabout, an enema is decidedly indicated, but the 
old notion that such clyster treatment is the plan to be adopted 
in all cases, is quite erroneous. The habitat of the oxyuris is not 
the rectum only, but the whole large intestine ; in fact its headquar- 
ters may be said to be the caecum. It is obvious that ordinary ene- 
mata cannot reach so far. In rebellious cases special apparatus 
whereby the whole intestines can be irrigated is recommended. 
Such is Hegar's tunnel system apparatus. Nothing is better as a 
destructive agent than warm or cold (pure) water — in water the 
parasites swell up and burst. A solution of soap is sometimes rec- 
ommended. After a general clearance by purgatives and enemata, 
it is well to instruct the parents to repeat the latter about once a 
week, even when the child seems in good health. With this purga- 
tive line of treatment it is, in my opinion, very important that a tonic 
plan should be joined. Indeed, I think the facts show that a double 
cause exists for the accumulation of these intestinal worms, and for 
the effects which they produce. So long as the ova of the parasites 
are imported into, or even by a chance develop in, a healthy intes- 
tine, they manifest no ill-effects, because the vigor of the intestinal 
movement never allows them to accumulate. Let there be, however, 
from any cause, a paresis of the bowel, or > a development of the 
mucus in which they can become concealed, and then they become 
the dangerous pests that I have described. The moral is : Coinci- 
dently (or commencing very shortly after the expulsive efforts) ad- 
minister iron tonics with, in some cases, strychnine or nux vomica, 
with a view of not only restoring the blood-making functions, but of 
giving strength to the weakened intestines. Finally, as regards pre- 
ventive treatment, without which all other means are of no avail, at 
the outset insist on scrupulous attention to diet. All the milk given 
and all the drinking-water should be previously boiled, for ova of 
ascaris lumbricoides can be imported by these vehicles. So, also, 



INTESTINAL PARASITES. 1011 

all the meat given should be well cooked. Especially all the food 
should be clean. It is through the soiled ringers of human kind that 
the ova are chiefly distributed ; any article of food, therefore, which 
passes through many hands, or is liable to be touched by dirty hands,, 
suspect. I am very much inclined to think that brown sugar is a, 
vehicle for importation — therefore I order white sugar to my patient. 
Above all, try to indoctrinate habits of strict cleanliness as regards 
the little patients themselves. With the view of killing ova, I order 
tar or carbolic acid soap to be used for the frequent washing of the 
body, and I make the parents keep the children's nails short, and 
brush them many times a day with tar-soap water. It is undoubted 
that the supply of the parasite is kept up by the conveyance by the 
fingers of ova from rectum to mouth. Alas, it is not always that 
these lessons can be adequately enforced, though I must say that 
among the poor I found rebellion against carefully expressed rules 
exceptional. The mothers of hospital patients are willing, for the 
most part, to learn, and glad to be taught. You may think my pre- 
cautions unnecessarily minute ; but I hold that the treatment of the 
affections to which I have directed your attention is on a par with 
the antiseptic method in surgery." 

The above advice, even the treatment modified as regards drugs, 
is sensible and practical. The use of colon flushing — if simple water 
destroys the parasites — is as important as it is harmless. I prefer 
hydrastis lx and ferrum mur. lx to any other form of intestinal 
tonic in children. 

The homeopathic symptomatic treatment will be of value when 
the intestinal secretions are at fault, but it does not expel the para- 
sites. If we restore the intestines to the normal state the worms 
will become quiescent. It should be remembered that children may 
present an assemblage of symptoms exactly resembling those caused 
by worms, but proceeding from other causes, such as cerebral irrita- 
tion, catarrh of the stomach and intestines, etc. For this reason it 
is always good practice, unless worms are discovered in the stools, to 
prescribe for the symptoms before we resort to vermifuges. If we 
desire to kill and expel these worms, santonine or napthalin lx in 
doses of one to five grains, followed by mercurius dulcis lx or cas- 
tor oil, must be used. 



1012 THE PRACTICE OF MEDICINE. 

TAPE -WORMS AND CYST -WORMS. 

" Taenia solium and cysticercus cellulosae cutis. The taenia solium 
is one of the most common of human tape-worms. In its perfect 
condition it usually measures from seven to ten feet long, but often 
exceeds that length. Its head or scolex, which is about as large as 
a small pin's head, or, to be more exact, between l-45th and l-35th 
of an inch in diameter, is succeeded by a delicate thread-like neck, 
which, gradually becoming broader and flatter and wrinkled trans- 
versely, merges ere long in the distinctly jointed body. The joints 
or proglottides are in the first instance much broader than they are 
long ; but gradually with their increase in size this relation ceases ; 
and although they still get broader, their length throughout the 
greater part of the strobilus exceeds their breadth. Towards the 
lower extremity, the quadrilateral joints measure on the average a 
quarter of an inch wide by half an inch long. The globose head 
presents four projecting suctorial discs placed at equal distances 
upon and a little above the equator ; and springing from its pole a 
rounded elevation, or rostellum, the margin of which is furnished 
with a double circle of hooks. The apparently homogeneous neck 
may be seen under the microscope to be transversely wrinkled at a 
very short distance from the head. The taenia solium is essentially 
an inhabitant of the small intestine, to the mucous surface of which 
it fixes itself by its hooklets and suckers. It is usually, as its name 
implies, solitary ; but two, three, or more are not infrequently asso- 
ciated, and occasionally much larger numbers. From the time of 
its entrance into the bowel until it reaches its full development, a 
period of three or four months usually intervenes ; and it may live 
in the bowel for many years, during which time it is constantly shed- 
ding its ripe proglottides and discharging ova into the alimentary 
canal." 

" The cysticercus cellulosae is chiefly known as a denizen of the 
flesh of pigs, in which it is sometimes present in vast numbers, rend- 
ering the pork ' measly.' And it is almost exclusively to the use of 
such, in an uncooked or imperfectly cooked condition, that the devel- 
opment of taenia solium in the human intestine is due. In the com- 
paratively rare cases in which the cysticercus infests the human body, 
it seems to occur mainly in the muscles, connective tissues, brain, 



INTESTINAL PARASITES. 1013 

eye, and serous membranes. It exists under the form of a round 
or ovoid vesicle, about the size of a pea or bean, but sometimes 
attaining that of a marble, formed of a transparent elastic membrane, 
containing a clear limpid fluid. Springing from one side of this 
vesicle is a wrinkled cylindrical neck, terminating in a head precisely 
similar to that of the taenia solium. The neck and head protrude 
externally after death, and may be made to protrude by pressure 
during life ; but in the ordinary living state, they are retracted within 
the vesicle, lying coiled up against one side of it. The conversion 
of the six-hooked embryo into a perfect cystic scolex occupies about 
two and a half months ; and the scolex may remain living in the tis- 
sues of its host for many years. 

"Tcenia mediocanellata, and cysticercus taenia m c. — This tape- 
worm, which was formerly confounded with the last, is equally com- 
mon. It presents a general resemblance to it both anatomically and 
in habit ; but it presents also characteristic differences. It attains 
a greater length, its joints are longer and broader, and its head 
also is two or three times as thick. The head, moreover, is fur- 
nished with four large round pigmented suckers, but with neither ros- 
tellum nor armature of hooklets ; the uterus, though exhibiting the 
same general arrangements as that of the taenia solium, is charac- 
terized by much more numerous and finer transverse processes ; and 
the ova, instead of being round, are oval, the long diameter differing 
little from the diameter of the egg of the taenia solium, the shorter 
diameter measuring about 1-8 5 0th of an inch. 

The cysticercus of this tape-worm seems especially to affect the 
ox, and it is, therefore, to the eating of imperfectly cooked beef that 
the introduction of scolex into the intestines is due. The cysticercus 
is a small oval vesicle, similar to that of the cysticercus cellulosae, 
but smaller than it, and furnished with a neck and head, of which 
the latter is identical with that of the adult sexual strobilus. It is 
not known to affect the human being. 

"JBothriocephalus latus. — This tape-worm is limited in its range 
to certain European countries, especially Belgium, Holland, Poland, 
Prussia, Russia, Sweden, and Switzerland. It is the largest of all 
tape-worms, not infrequently attaining a length of twenty-five feet 
and upwards, and a breadth of more than half an inch at its widest 
part. The head is ovoid in form, measuring about l-10th of an 



I 



1014 THE PRACTICE OF MEDICINE. 

inch in length by l-26th in breadth, and presenting two opposite 
longitudinal deep grooves or suckers, but no hooklets. The neck, 
which is comparatively narrow, soon becomes transversely wrinkled ; 
and as it widens out and retreats from the head, the wrinkles divide 
it into successive segments. The segments gradually increase in all 
their dimensions, but for the most part continue of greater width 
than length ; and are specially characterized not merely by their gen- 
eral form, but by the fact that the genital pore is placed in the cen- 
tre of each flat surface, and that the uterus forms a small rosette, of 
which this pore is the centre. The ovum never become matured within 
the uterus, and usually escape thence into the bowel, while the pro- 
glottis is still a portion of the strobilus. After the discharge of their 
ova, the joints diminish in size, and become shrivelled and elon- 
gated. The eggs are of oval form, measuring about 1-370 of an inch 
by l-570th, and have a firm brown shell, which opens by a lid at 
one end. The embryo on its escape from the egg is provided with 
oilia, which it soon loses, and then presents the common six-hooked 
character. The cysticercus of this tape-worm has long been believed 
to infest some fish or other aquatic animal. The correctness of this 
surmise has been established by Dr. Braun, of Dorpat (a locality 
where the worm is comparatively common), who, on examining the 
fish brought to market, discovered that the muscles, with the liver 
and other viscera, of the pike and eels were in large proportion 
abundantly invested with the scolices of the parasite. Moreover, on 
feeding dogs and cats with the infected tissues, bothriocephali were 
developed in their bowels. 

/Symptoms. — "The symptoms to which tape-worms give rise are on 
the whole trivial and unimportant. Many of those who are infested 
by them enjoy perfectly good health ; and many more make them 
the scapegoats of all the ailments (imaginary or other) from which 
they happen to suffer during the residence of these parasites within 
them. Among the symptoms which are referred to their presence 
are : pain and discomfort in the belly, capricious appetite, variable 
condition of bowels, itching at the nose and anus, depression of spirits, 
emaciation, and hysterical, epileptic, or other nervous phenomena. 
The list might easily be extended ; but when we consider that, not- 
withstanding all the evil influences which have been attributed to 
them, they are probably never diagnosed or even suspected to be pres- 



INTESTINAL PARASITES. 1015 

ent until their joints have been detected in the stools, it is obvious 
how vague and on the whole how apocryphal all these influences are. 
The only way in which the presence of tape-worms can be absolutely 
recognized is by the discovery of their joints either in the stools or 
about the anus or on the body-linen, and of their eggs by the micro- 
scopic examination of the faeces. 

"The cysticercus cellulosse causes no symptoms unless it be lodged 
in some delicate or vital organ, such as the eye or cortex of the brain, 
and even then the symptoms are not specific." (Bristowe.) 

Treatment. — The treatment of tape-worm is uncertain, because the 
drug that will destroy and expel it in one case will not in another. It 
has been supposed by some that intestinal parasites cannot exist or 
gain lodgment unless there is some abnormal condition of the intes- 
tinal secretions which favor their life. Those who favor this opin- 
ion assert that we need not attempt to destroy the worm ; that we 
should use medicines which are supposed to remove the diseased con- 
dition of the intestinal canal. On the other side are found those who 
believe that parasites exist only in the healthy intestine, and leave or 
are made ill by any disease of that tube. In this way they account 
for the convulsions and other nervous phenomena which appear when 
worms infest the intestines. I am inclined to the latter theory, 
although I admit that worms may propagate to such an extent that 
their numbers may cause disease conditions. These theories are not 
as applicable to tape-worm, as to the other parasites — ascaris and 
lumbrici. 

My experience has been that when we combine a symptomatic 
with a parasiticidal treatment we shall meet with the best results. 
There are but few trustworthy remedies for tape- worm. If we desire 
their death or expulsion, the oleo-resin of male fern (Felix mas.) 
has long had a good reputation. It has been used in doses from 
30 to 120 minims, given in the early morning before eating and fol- 
lowed shortly by a dose of castor oil. These doses have, however, 
caused violent and dangerous symptoms. I begin with ten drops, 
and if no segments appear, increase to twenty drops. If no good 
results appear after four doses, it is not the remedy. 

Granatum (bark of the root of pomegranate) is sometimes effi- 
cient. In the doses prescribed until lately — four ounces of a decoc- 
tion of the fresh root — it is intensely unpalatable, but a French chem- 



1016 THE PRACTICE OF MEDICINE. 

1st, Tanret, has isolated from the bark an alkaloid called pelletier- 
ine which is an active tsenicide. On animals it acts like curare, 
causing paralysis of the motor nerves. It may act on the tape-worm 
in the same manner. The dose of this alkaloid is one to four grains, 
according to the age of the patient. It should be given fasting, or 
on a scant milk diet. 

Kamela comes from India, where it is largely used for tape-worm. 
It is an active purgative and needs no adjuvant. The tincture, in 
doses of ten to twenty drops, can be given every four hours until its 
laxative effects appear. 

Kousso (an Abyssinian drug) can be given in doses of half an 
ounce of the powdered flowers in the morning, fasting ; or the alka- 
loid koussin, in doses of ten to twenty grains wrapped up in a wafer. 
It is said to be unsafe to give to pregnant women. 

Salicylic acid is said to have destroyed tape- worm. For adults 
give three grains every hour or two until twenty-five grains are taken, 
then give a purge. 

Thymol has been successfully used by Italian physicians, who give 
it as follows : " Half an ounce of castor oil in the evening ; the next 
morning two drachms of thymol, divided into twelve doses, one to be 
given every quarter of an hour, and twenty minutes after the last 
dose, another dose of castor oil." 

Cocoanut has lately gained some reputation. Various medical 
journals have reported cases of expulsion after a few days' exclusive 
diet of grated cocoanut. It is certainly a harmless and agreeable 
remedy, and should be further tested. 

Pumpkin seeds have gained a deserved reputation. I have used 
them successfully in many cases. Two ounces of the seeds may be 
bruised in a mortar ; sugar and a little cream added. This dose 
should be taken at 9 p. M., after a light supper of bread and milk, 
and the same dose in the morning before breakfast. A few hours 
after this last dose an active purgative — castor oil, Eubinat water, or 
Epsom salts — may be given. Dr. Wolff asserts that the active prin- 
ciple is a resin which is effectual in a dose of fifteen grains. Dr. 
Heckel's investigations show that the fourth coat of the seed, starting 
from the outside, i, e., the coat next the meat, contains the active 
taenicidal principle (the resin), and not as had been supposed, the 
fatty oil in the meat. 



INTESTINAL PARASITES. 1017 

It should be remembered that the patient is not really cured of 
his parasite until the head of the worm has been expelled, for if the 
head is left it will soon propagate another worm. The thread-like 
portion should be carefully examined with a magnifying glass before 
it is decided that the head has been expelled. Even then, the neck is 
so delicate that it may have been detached and lost after its expulsion. 

Tribromphenol is recommended by Dr. Gruum. He says one- 
half to three grains will expel the taenia mediocanella and the both- 
riocepholus lata. He gives only one dose. 

I have expelled several tape-worms with the following : ^ — Oleo- 
resin, male fern, two drachms.; croton oil, two drops, in half an ounce 
of an emulsion of acacia, one-half was taken in the morning, fasting. 
The worms measured twenty and thirty feet in length. 

Creolin has been used successfully. Dr. Engelke, of Brazil, uses 
it as follows : fifteen minims of creolin mixed with powdered licorice 
root, and given in the evening and early in the morning. The first 
dose is preceded by a cold infusion of senna. The worm is expelled 
a few hours after the morning dose. Instead of the senna I would 
advise adding a drop or two of croton oil to the last dose of creolin. 

Dr. Stephen reports the expulsion of tape-worms by means of 
chloroform, even where all other taenicides had been employed in 
vain. He applies the following formula : 

1^ Chloroform grms. iv. (fi. dr. i.). 

Syrup grms. xxx. (fl. drs. vi.). 

To be taken in four parts at 7, 9, and 11 o'clock in the morning and at 1 
o'clock in the afternoon. The patient also takes thirty grms. (one fluid ounce) 
of castor oil at noon. The chloroform was always well borne, it is stated. 

Many years ago I remembered to have read in one of our jour- 
nals, the 30th dilution of male fern seriously recommended for tape- 
worm. Anyone conversant with the history of the origin and devel- 
opment of this parasite in the human body must consider such a 
prescription as verging on the ridiculous. As well might the 30th 
of arnica or calendula be prescribed for a wound in which remained 
a splinter or any foreign substance ; or any internal medicine to expel 
a tick or jigger from the skin. I could not believe any physician 
now living held to any other belief, and was prompted to write to 
one who, if any, claims to represent the original teachings of Hahn- 
emann. In reply to a letter of inquiry, I received the following. I 



1018 THE PRACTICE OF MEDICINE. 

give it without a word of comment, which I think is unnecessary. 
" The tape-worm is as easily eradicated as the pin-worm, and in 
precisely the same way — by the constitutional remedy. It may 
require more time, but the longest way round may be the safest way 
home. In my experience, the forcible expulsion of the tape-worm 
does not remove the cause (?) and should be placed on the same basis 
as cauterizing a chancre or suppressing a gonorrheal discharge. It 
never cures. It may produce a metastasis ; it cannot rid the patient 
of sickness." 



THE END. 



INDEX 



Abscess, in Appendicitis, 412 ; of the Brain (see Encephalitis) 919 ; of the Lung, 352. 

Acids, in Cholera, 101. 

Aconite, compared with Veratrum, 760 ; in Neuralgia, 940 ; in Pneumonia, 346, 

760; valuable in Hsemoptisis, 332. 
Aconitine, in Sciatica, 955; in Tachycardia, 713. 
Adenitis, tubercular, 110. 

Allen, Dr. H. C, Allen edition of Dr. Gregg on Consumption, 116. 
Allbutt, Dr. C, " Gastric Ulcers," 390. 
Albuminuria (see Bright's Disease), 605. 
Aloin, in Biliousness, 422; in Constipation, 496. 
Amyl Nitrite (see Nitrite of Amyl). 
Amyotrophic Lateral Sclerosis, 989. 
Ansemia, 146; Arsenic in, 156; Cerebral, 891 ; Diet in, 159; Iron in, 155; in 

Diabetes, 184; of Bright's disease, 608; Primary, 147; Secondary, 148; 

Spinal, 931; Treatment of Dr. J. Cheron, 161, (Neusser) 152. 
Angina Pectoris, 685, 749; due to high Arterial Tension, 779. 
Antipyrin, in Diabetes Insipidus, 193. 
Aortic Incompetency, 684; Stenosis, 687. 
Apis mel., in Meningitis, 921. 
Apomorphine, emetic use in Headaches, 902, 906. 
Apoplexy (see Cerebral Hemorrhage), 915; Pulmonary (see Hemorrhage from 

the Lungs), 330. 
Appendicitis, 408, 410; Catarrhal, 412; Perforative, 413; Ulcerative, 412. 
Argyll Robertson's Pupil, 980. 

Arndt's " System of Medicine " articles on Relapsing fever, 16; Typhus fever, 15. 
Arnica, in Cerebral Hemorrhage, 916 ; in Intercostal Neuralgia, 947. 
Arsenic, in Anaemia, 156; in Asthma, 297; in Bright's disease, 615; in Chronic 

Gastritis, 375; in Gastric Ulcer, 392; in Neuralgia, 939; in Pruritus Ani, 

452; in Scarlet fever, 42; in Senile Heart, 742; in Tabes, 981; Poisoning 

(see Neuritis), 965. 
Arterial Tension, High, 768, 794; Low, 779, 794. 

Arterio-sclerosis, 814; a Cause of High Tension, 774; in Bright's disease, 594, 596. 
Ascaris Lumbricoides, 1004. 
Ascites, 456. 

Aspiration in Pleuritic Effusion, 359. 
Asthma, a Neurosis partly, 292; Arsenic in, 297; Bronchial or Spasmodic, 292; 

Cigarettes, 296 ; Grindelia in, 301 ; Lobelia in, 295 ; Nitro-glycerine in, 296 ; 

of Millar, 277; Posture in, 295; Ventilation in, 294. 
Astringents, useful in Diarrhoea, 398. 
Ataxy, Hereditary, 987; Locomotor, 978. 
Atheroma (see Arterio-sclerosis), 814. 
Atrophy, of the Prostate, 676. 
Aulde, Dr. John, Treatment of Grippe, 68. 



1022 INDEX. 

B. 

Babcock, Dr. R. H,, 831. 

Bacillus, of Cholera, 101 ; of Diphtheria (Loeffler) the Diagnostic distinction from 

Croup, 286; of Tetanus, 80; of Tuberculosis, 108, 111. 
Balkiness, a kind of Hysteria, 858. 
Baruch, Dr. Simon, an Opponent of direct intestinal Antisepsis in Typhoid 

fever, 24. 
Basedow's Disease (see Diseases of the Thyroid Gland), 202; (see Persistent 

Tachycardia), 701. 
Belladonna, in Neuralgia, 939; in Phlebitis, 804; in Scarlet fever, 41. 
Beri Beri, 966. 

Bile, increased Secretion and Expulsion of, 487. 
Bilharzia Haematobia, 571, 629. 
Biliousness, 490. 
Black Measles, 46. 

Bladder, Catarrh of (see Cystitis), 628; Irritable, 642. 
Bleeders (see Haemophilia), 216. 
Blue Mass, in Headache, 906. 
Boils (see Furuncles), 237. 
Bothriocephalus Latus, 1013. 
Bradycardia, 724. 
Brain, Anaemia of the, 891; Congestion of the, 886; Irritation of the, 884 j 

Tumors of the, 917. 
Breast, Cooper's Irritable, 946; Pain (see Angina Pectoris). 
Bright's Disease, 585. 
Bristowe, Dr. J. S., Definition of Thrombosis and Embolism, 804; Description of 

Gout, 197. 
Broadbent, Dr. W. H., «The Pulse," 788. 
Bromides, Palliatives in Headaches, 902, 911. 
Bromism, in the Treatment of Epilepsy, 852. 
Bronchitis, 305; Capillary, 336; Catarrhal, Acute, 306; Chronic, 307; Climate in, 

324; Fcetid, 308. 
Bronchocele (see Goitre), 202. 
Broncho-Pneumonia, 336. 
Bronchorrhcea, 308. 

Bryonia, in Acute Rheumatism, 142; in Meningitis, 921. 
Bryson, Dr. Louise, Symptoms in Persistent Tachycardia, 706. 
Bulbar Paralysis, 992. 

Burnett, Dr. J. C., "Greater Diseases of the Liver," 508; Treatment of Tuber- 
culosis, 131. 



Cactus, in Haemoptysis, 333; in Meningitis, 926. 

Calculus, biliary (gall-stones), 526; renal, 576; mistaken for Neuralgia, 950, 

Calomel, in Bright's disease, 603. 

Camphor, a stimulant in Collapse, 925; in Cholera, 102, 103. 

Cancer, of the liver, 553; of the stomach, 394. 

Cancrum oris (see Gangrenous Stomatitis), 363. 

Carbolic acid, for Carbuncles, 79; in Goitre, 205; injection for boils, 238. 

Carbuncle, 78. 

Carcinoma ventriculi, 394. 

Cardiaesthenia, 864. 

Cardialgia (misused for Gastralgia), 385. 

Carduus, in varicoses, 810. 

Castration for Osteomalacia, 224. 



INDEX. 1023 

Catarrh, chronic (see chronic Coryza), 242; in Rickets, 232; nasal, 247; of the 
bladder, 628; of the intestines, 396; of the stomach, 490; acute, 370; chronic, 
372. 

Catarrhus sestivus, 254. 

Ceanothus, a spleen remedy, 562. 

Cephalalgia (see Headache), 896. 

Cerebral hemorrhage, 915. 

Cerebrine, 982. 

Cerebrsesthenia, 864. 

Charcot, Dr., pathology of Gout, 200. 

Chase, Dr. J. O., treatment of Rickets, 235. 

Chelidonium, in hepatic congestion, 509. 

C heron, Dr. J., Scarification of the Os Uteri in Chlorosis, 161. 

Cheyne-Stokes breathing, 595; in Ura3mia, 623. 

Chicken-pox, 39. 

Childhood, the pulse in, 797. 

Chloral hydrate, as a hypnotic, 876; in Hay fever, 257; in Scarlet fever, 44. 

Chlorosis (see Anaemia), 159; Iron in, 160; treatment of, Dr. Cheron's, 161; Dr. 
Loewenthal's, by suppressing the menses, 161. 

Cholera asiatica, 95; acids in, 101; bacillus of (Koch), 96; Camphor in, 102, 
103; Copper in, 100, 104; incubation stage of, 97; modes of infection, 96; 
prevention of, 99; salt solution in, 105; treatment of in India, 104; Yeratrum 
album in, 104. 

Cholera infantum, 403. 

Chorea, 837; cardiac, 847; Hyoscyamus in, 844, 849; of pregnancy, 847. 

Cigarettes, in Asthma, 296. 

Cimicifuga, in anaemic Headaches, 900; in Chorea, 841; in spinal Anaemia, 934. 

Cirrhosis of the liver, 550; Glissonian (perihepatis), 550. 

Clark's, M., intestinal antisepsis in Typhoid fever, 24. 

Clark's, Sir Andrew, Phthisis not always tubercular, 111. 

Climate, for Asthma, 304; for Bright's disease, 598; for Bronchitis, 324; for 
chronic Laryngitis, 283; for Neuraesthenia, 870; for Tuberculosis, 117; 
influence of, on Heart disease, 825 ; influence of, on the liver, 506 ; of Flor- 
ida, 121-126. 

Codeine, for pain of gastric Ulcer, 392. 

Colchicum, in Gout, 199. 

Cold, common (see Coryza), 239; infectious nature of, 242. 

Cold not always destructive to disease germs, 32. 

Colic, hepatic (see Gall-stones), 526; intestinal, 401; lead, 965; renal, 577. 

Colitis, 396; membraneous, 416. 

Congestion, of the brain, 886; of the spinal cord, 929. 

Constipation, 418; a cause of high arterial tension, 773, 778. 

Consumption (see Tuberculosis), 107. 

Convallaria, in Tachycardia, 711. 

Convulsions of children, in acute Diarrhoea, 401, 402 ; lithaemic, 480; uraemic, 623. 

Cooper's " irritable breast," 946. 

Copper, in Cholera, 100, 104. 

Coronilla varia, in paroxysmal Tachycardia, 701. 

Corpulency, 162; Phytolacca in, 171. 

Corrigan's pulse, 685. 

Coryza, acute, 239; chronic, 242. 

Cough, 258; aural, 265; dry, 308; from larynx, 261; from lungs and pleura, 
260; from pharynx, 262; functional, 262; gastric, 266; hepatic, 266; pharyn- 
geal, 263; reproductive, 267; "Whooping, 72; winter (see chronic Bronchi- 
tis), 307. 



1024 INDEX. 

Coulson, Dr. W. J., « Diseases of the Bladder " 625, 628. 

« Coup de Soleil," 880. 

Croup, false, 834; (see membraneous Laryngitis), 284. 

Curshmann's spirals (see Asthma), 294. 

Cyst-worms, 1012. 

Cystitis, acute, 624; chronic, 628. 

D. 

Dementia paralytica, 974. 

Dengue fever, 16. 

Diabetes, in Pancreatitis, 559; insipidus, 191; mellitus, 174; diet in, 180, 182; 
geography of, 175; symptoms of, 176, 179; treatment of, 180. 

Diarrhoea, 396; acute dyspeptic, 401; fatty, 396; in Rickets, 232. 

Diet, in Anaemia, 159; in Asthma, 303; in Bright's disease, 598; in Biliousness, 
502; in Bronchitis, 324; in Constipation, 420; in Diabetes, 180, 182; in 
Corpulency, 166, 169; in Cystitis, 634; in Diarrhoea of children, 403; in 
Dysentery, 94; in Gall-stones, 545: in gastric Ulcers, 391; in Gastritis 
chronica, 373; in Gout, 199; in increased secretion and expulsion of bile, 
489; in Jaundice, 521; in Lithaemia, 486; in Pneumonia, 346; in Rickets, 
235; in Scurvy, 217; in senile Heart, 735; in Tuberculosis, 132; in Typhoid 
fever, 27. 

Digitalis, in aortic Insufficiency, 686; in Pneumonia, 763; in senile Heart, 738, 741. 

Dilatation and hypertrophy, 690. 

Diphtheria, 53; in heart failure, 59; of the rectum, 453; Mercury and its prep- 
arations in, 56; statistics of, not trustworthy, 54; treatment of, 55; local, 55. 

Douche, rectal, in inflamed prostate, 660. 

Dowling, Dr. J. W., on Lithsemia, 476. 

Dropsy in Bright's disease, 609; of the abdomen (see Ascites), 456. 

Dry mouth, 364. 

Dujardin-Beaumetz, " Diseases of the Liver," 458. 

Duncan, Dr. T. C, " How to be Plump," 174. 

Dunn, Dr. W. A., acute laryngeal (Edema, 271; hypersesthetic Pharyngitis, 268; 
nasal Stenosis, treatment of, 273. 

Duodenitis, 396. 

Duodenum, Ulcer of the, 389. 

Dwelling conditions opposed to Tuberculosis, 129. 

Dysentery, 85; classification of, 85; diet in, 94. 

Dyspepsia, chronic (see Gastritis), 372; hepatic, 480. 



Ebstein, Dr., diet in Corpulency, 166. 

Electricity in Jaundice, 525. 

Emaciation (see Malnutrition), 171. 

Embolism, 804, 812. 

Emphysema, 350. 

Empyema, surgical treatment of, 359. 

Encephalitis, chronic diffuse, 974; purulent, 919. 

Endocarditis, 680. 

Enemata, in Typhlitis, 410; of carbolic acid in rectal Catarrh, 449; of Opium in 

Diarrhoea, 403; in Dysentery, 93. 
Enteritis, catarrhal, 396. 

Entero-colitis, of children (see Dysentery), 396. 
Ephemeral fever, 1. 



INDEX, 1025 

Epidemic in Influenza (Grippe), 67. 

Epilepsy, 850; spinal, in multiple Sclerosis, 973. 

Epistaxis, 276. 

Ergot, in Congestion of the brain, 888; in enlarged prostate, 673; in Haemoptysis, 

331, 333. 
Eruptive fever, 37. 

Erysipelas, 63 ; allied to Puerperal fever, 64 ; not idiopathic, 63 ; treatment, local, 65. 
Euonymin, in Biliousness, 492 ; in Bright's disease, 604; in membraneous Colitis, 417. 
Exalgine, in Chorea, 843. 
Exercise, in Tuberculosis, 130. 
Exopthalmos, bandaging the eyes for, in Tachycardia, 718. 



Falligant's, Dr. Louis A., treatment of Dengue fever, 16; of Yellow fever, 35. ., 

Fatty stools not necessarily a sign of pancreatic disease, 396. 

Fever, catarrhal (see acute Coryza), 239; Dengue, 16; Ephemeral, 1; eruptive 
infectious, 37; fermentation (see Septicaemia), 209; Hay, 254; Malarial, 2; 
(Pernicious, 11; Remittent, 10; Typho-, 14; Relapsing, 16); Rocky Moun- 
tain, 32; Scarlet, 40; Sewer-gas, 28; Typhoid, 17; Typhus, 15. 

Filaria sanguinis hominis, 571. 

Fissure of the rectum, 440. 

Florida, climate of, 121, 126; few cases of Heart disease in, 822; for neuraes- 
thenics, 870; free from Sunstroke, 881; how to reach, 126. 

Fothergill, Dr. J. Milner, diet in Biliousness, 502. 

Friedreich's disease, 987. 

Fucus vesiculosis (contains Iodine), for Corpulency, 169. 

Furuncle, 237. 

G. 

Gall-stones, 520, 526. 

Garrod, Dr., causes of Gout, 196. 

Gastralgia, 384. 

Gastritis, acute, 370, chronic, 372. 

Gastrodynia, 384. 

Gee, Dr., Haematuria in children a sign of Scurvy, 219. 

Gelsemium, in Chorea, 841; in hyperaemic Headache, 902; in Neuralgia, 943; 

in Sunstroke, 882; in Tetanus, 81. 
General paralysis of the insane, 974. 
Geography, of Diabetes, 175; of Heart diseases, 821; of Pneumonia, 343; of 

Tuberculosis, 107. 
Geranium, a useful astringent in Enteritis, 399. 
German Measles, 51. 

Germs, not always destroyed by freezing, 32. M 

Gland Thyroid, diseases of the, 201. : 

Glands, diseases of the salivary, 364; Tuberculosis of the lymph, 110. 
Glonoin (see Nitro-glycerine). 
Glossy skin, from Neuritis, 959. 
Glycerine, in Gall-stones, 542; in renal colic, 582. 
Glycosuria (see Diabetes mellitus), 174. 

Goitre, Bronchocele, 202; treatment of, 718, 203, by Iodine, 203, in India, 206. 
Goitre, exophthalmic (see persistent Tachycardia), 701. 
Gold, in anaemic Headache, 901; in Angina pectoris, 752; in Epilepsy, 853; in 

Hysteria, 860; in spinal Anaemia, 935; in Tachycardia, 708. 
Gonorrhoea, 135. 



i 



£ 



1026 INDEX. 

Gout, an hereditary disease, 196; causing senile Heart, 731; Colchicum in, 199; 

Ichthyol in, 198* kidneys in, 197; Opiates not advised in, 199; (see Lith- 

aemia), 485. 
Grand mal, 850. 

Graves' disease (see persistent Tachycardia), 701. 
Gregg, Dr., on Tuberculosis, 108, 116. 
Grindelia robusta, in Asthma, 301. 
Grippe, 67; compared with Typhoid fever, 70; Gelsemium in, 68; origin of 68; 

similar to Rheumatism, 69. 

H. 

Haematemesis, diagnostic sign of, 388. 

Hematuria, 571. 

Hemoglobinuria, 575. 

Haemophilia, 216; not to be confounded with Purpura, 216. 

Haemoptysis, 686 ; diagnostic sign of, 388 ; (see Haemorrhage from the Lungs), 330. 

Haemorrhage, from the brain (cerebral), 915; from the lungs, 330; from the 

nose, 276; from the stomach, 387. 
Hamamelis, for varicose veins, 809. 

Hay fever, 254; Dr. Alexander Rixa's treatment of, 255. 
Hahnemann, treatment of Syphilis, 84. 
Headache, 896 ; bilious, 905 ; dyspeptic, 905 ; from cerebral Anaemia, 898 ; from 

cerebral Hyperaemia, 901 ; from cerebral tumors, 918 ; from eye-strain, 907 ; 

gastric, 905; malarial, 914; menstrual, 903; nervous (neuraesthenic), 909; 

sympathetic, 902; syphilitic, 914; toxaemic, 912. 
Heart diseases, 680; geography of, 821. 
Heart, Chorea of the, 847; inflammation of the, 680; in Pneumonia, 756; pain 

in the, 746; rapid (see Tachycardia), 691; relation of, to pulse, 791; senile, 

731, caused by Gout, 731 ; slow (see Bradycardia), 724. 
Heart failure, in Diphtheria, 59. 
Heart sounds, in Bright's disease, 595. 
Heat-stroke, 880. 
Hemorrhoids, 432; internal, 434. 
Hepatitis, acute, 547; chronic (interstitial), 550. 
Herpes zoster, 946. 

Hughes, Dr., Richard, treatment of Dengue fever, 16; of Gout, 200. 
Hydrastis, haemostatic effects of, 334. 
Hygiene of the rectum, 427. 

Hyoscyamus, in Chorea, 844, 849; in dry Cough, 310. 
Hyoscine, in Epilepsy, 857; in Insomnia, 875. 
Hyperaemia, cerebral, 886; spinal, 929. 
Hypertrophy of the prostate, 666. 
Hypertrophy and dilatation, 690. 
Hysteria, 857. 

I. 

Ichthyol, in acute Rheumatism, 145. 
Icterus (see Jaundice), 518. 
Ileitis, 396. 

Incompetency of the aorta, 684. 
Incontinence of urine, 647. 
Incubation, stage of, in Cholera, 97. 
Infection, mode of, in Tuberculosis, 108. 
Infectious nature of Cholera, 96. 



INDEX. 1027 



Influenza, epidemic (see Grippe), 67. 

Insane, general paralysis of the, 974. 

Insolation, 880. 

Insomnia, 871. 

Intestinal obstruction, 424. 

Intestines, diseases of the, 396. 

Intussusception, 425. 

Invagination, 425. 

Iodide of potassium, in Meningitis, 921; in Neuralgia, 955. 

Iodides in Angina pectoris depending on Arterio-sclerosis, 752. 

Iodine in Corpulency, 169; in Goitre, 203; in Pancreatitis, 557. 

Iron in Anaemia, 155; in Chlorosis, 160. 

Irrigation of the stomach, 402, 425. 

Irritable rectum, 450. 

Isolation, methods of, in Scarlet fever, 43. 



J. 

Jamaica dog- wood as a hypnotic, 877. 

Jambul (Syzygium jambolanum), in Diabetes, 184. 

James Dr. B. W., "American Resorts and Climates," 117. 

Jaundice, diet in, 521; Icterus, 518; without obstruction, 512. 

Jejunitis, 396. 

Joints, hysterical, 862. 

K. 

Kak-ke, 966. 

Keyes Dr. E. L., Atrophy of the prostate, 676; chronic Prostatitis, 661; Hyper- 
trophy of the prostate, 666; treatment of Gonnorrhcea, 137; treatment of 
Syphilis, 84. 

Kidneys, congestion of the, 570; diseases of the, 569. 

Kippax Dr. J. R., description of Chicken-pox, 40, of Relapsing fever, 16, of 
Small-pox, 38, of Typhoid fever, 15; treatment of Dengue, 16, of Sewer- 
gas fever, 30, of Yellow fever, 36. 

Kissing, in Tuberculosis, 113. 

Koch, Dr. Robert, Bacillus of Cholera, 96, of Tuberculosis, 108 ; Lymph in albu- 
minuria, 606. 

L. 

La Grippe (see Grippe), 67. 

Lactucarium, syrup of, in cough, 310. 

Laennec's perles, in Asthma, 294. 

Landry's paralysis, 962, 971. 

Larynx, acute oedema of the, 271. 

Laryngismus stridulus, 277, 832; in Rickets, 233. 

Laryngitis, catarrhal acute, 280, chronic, 282; membraneous, 284; not always 

diphtheritic, 285. 
Laryngitis stridulosa in Rickets, 233. 
Lavage (see irrigation of the stomach), 402, 425. 
Lead-poisoning (see Neuritis), 965. 
Learning Dr., on Cough, 258. 
Leanness (see Malnutrition), 171. 
Lemons in Scurvy, 218. 
Lettuce for Cough, 310. 
Lilienthal, Dr. S., " Repertory of Diabetes," 186-188. 



1028 INDEX. 

Lithsemia, 474; functional disorders from, 479; Locomotor Ataxia from, 482. 

Lithium salts in Lithsemia, 484. 

Liver, action of drugs on, 464; Cancer of the, 553; Cirrhosis of the, 550; conges- 
tion of the, 505, in children, 511; fatty, 552; functional disorders of the, 
458 ; Hyperemia of the, 505 ; yellow Atrophy of the, 550. 

Lobelia in Asthma, 295. 

Locomotor ataxia, 987; from Lithsemia, 482. 

Loewenthal Dr., Chlorosis treated by suppressing the menses, 161. 

Lumbago, 949. 

Lungs, Abscess of the, 352 ; active congestion of, 325 ; Gangrene of the, 349 ; hem- 
orrhage from the, 330; oedema of the, 328; passive congestion of the, 326. 



M. 

Malarial fever, 2; pernicious, 11, remittent, 10, simple intermittent, 2, typho-, 14. 

Massage in constipation, 421. 

Malnutrition, 171. 

Mays Dr. T. H., nervous origin of Tuberculosis, 109, 131. 

Measles, 46. 

Meningitis, acute simple, 919; cerebro-spinal, 922; symptoms resembling acute 
Pericarditis, 919. 

Meningo-encephalitis, 974. 

Mercury, in Biliousness, 491; in Diphtheria, 56, 57; in Dysentery, 88; in Head- 
ache, 906 ; in high Arterial tension, 777. 

Millard Dr. H. B., treatment of Bright's disease, 613. 

Mitral Stenosis, 689. 

Mollities ossium (see Osteomalacia), 223. 

Morbus Brightii, 585. 

Morphine, in Gall-stone colic, 536; in Headache, 911; in pseudo- Angina, 752; in 
Renal colic, 582. 

Mouth, diseases of the, 361. 

Muguet (see parasitic Stomatitis), 362. 

Multiple sclerosis of the brain and spinal cord, 973. 

Mumps (idiopathic Parotitis), 76. 

Muscular atrophy, hereditary and juvenile form of, 993; progressive spinal, 989; 
pseudo hypertrophic, 993. 

Myalgia, diagnosis between and Neuralgia, 194. 

Myelsesthenia, 864. 

Myelitis, 967 ; acute of the anterior horns, 967. 

Myocarditis, 680. 

Myxcedema, 207. 

McBurney's Dr. Charles, diagnostic sign in Appendicitis, 414. 



N. 
Nasal catarrh, 247. 

Nasal stenosis, 273; Dr. Dunn's treatment, 273. 
Nephralgia, 569. 
Nephritis (Bright's disease), 585; acute, 585; chronic Interstitial, 591; chronic 

Parenchymatous, 589 ; diffuse, 585. 
Nephrolithiasis, 576. 

Nervous exhaustion (see Neurasthenia), 862. 
Nerve vibration, 998. 
Neurasthenia, 862; spinal, 931. 






INDEX. 1029 

Neuralgia, 936; cervico-brachial, 944; cervico-oceipital, 944; intercostal, 946; 
lumbar, 949; sciatic, 951; of high Arterial Tension, 775; of the rectum, 450. 

Neuritis, 958 ; alcoholic, 964 ; endemic, 966 ; from lead poisoning, 965 ; localized, 
959; multiple, 960; optic,of cerebral Tumors, 918. 

Neuromata, 967. 

Neusser Dr., treatment of Anaemia, 152. 

Nitrite of Amyl in Anaemic Headache, 901 ; in Angina pectoris, 751 ; in senile 
Heart, 744. 

Nitro-glycerine, in Asthma, 296; in Bright's disease, 603; in cerebral Hemor- 
rhage, 603, 916; in Chlorosis, 160; in Heat stroke, 882; in high Arterial 
Tension, 778; in Nephritis, 589; in senile Heart, 743; in Tachycardia, 709. 

Nose bleed, 276. 

Nux vomica, in chronic Gastritis, 376. 

Nystagmus, 973. 

O. 

Obesity (see Corpulency), 162. 

Obstruction* Intestinal, 424. 

(Edema, acute laryngeal, 271 ; of the lungs, 328. 

(Esophagus, Inflammation of the, 369; Spasm of the, 369. 

Olive Oil in Gall-stone colic, 538. 

Opium enemata, in Diabetes, 183; in Dysentery, 93; in Appendicitis, 415; inju- 
rious in Bright's disease, 608; injurious in Gout, 199; to be avoided in He- 
patitis, 549; to quiet peristaltic unrest, 386. 

Optic Neuritis, 918. 

Ordway Dr. L. D., on Mountain fever, 33. 

Osier Dr. William, Anaemia, diagnosis of, 149; Arterio-sclerosis, 817; descrip- 
tion of Appendicitis, 410; History of Cholera, 95; prognosis in Diabetes, 
179; symptoms of Broncho-pneumonia, 337; Tuberculosis, 107, 110. 

Osteomalacia, 223. 

Ovariotomy in Osteomalacia, 224. 

Oxaluria, associated with Nephralgia, 570. 

Oxyuris vermicularis, 1008. 

P. 

Pain in the heart, 746. 

Palsy, shaking, 834. 

Pancreas, diseases of the, 553. 

Pancreatitis, acute, 554; suppurative, 555. 

Papillae, rectal, diseases of the, 447. 

Papoid in chronic Gastritis, 377. 

Paracentesis for Pleurisy, 359. 

Paralysis, agitans, 834; acute ascending, 971; acute atrophic, 969; atrophic spinal, 

969; General, of the Insane, 974; Glosso-labio-laryngeal (see Bulbar), 992; 

hereditary ataxic, 987; Infantile spinal, 969; Landry's, 962, 971. 
Paraplegia, Ataxic, 985; Spastic, 984. 
Parasites, intestinal, 1004. 
Paratyphlitis (see Appendicitis), 408. 
Parkinson's disease (see Paralysis agitans), 834. 
Parotitis, idiopathic (Mumps), 76; symptomatic, 78. 
Pellagra, 988. 
Pericarditis, 680. 
Peristaltic unrest, 386. 
Peritonitis, 453. 



1030 INDEX. 

Perityphlitis (see Appendicitis), 408. 

" Perles " of Laennec, in Asthma, 294. 

Pernicious malaria, 11. 

Pharyngitis, 268; hypersesthetic, 268. 

Phenacetin, as a Hypnotic, 877; in Headache, 911 ; in Incontinence of Urine, 653; 
in Neuralgia, 940, 948, 956 ; in Sunstroke, 883. 

Phlebitis, 803. 

Phlebo-sclerosis, 811. 

Phlegmasia alba dolens, 806. 

Phloridzin, in Diabetes, 185. 

Phosphorus, for the heart in Pneumonia, 764; in Bright's disease, 617; in spinal 
Anaemia, 934. 

Phthisis (see Tuberculosis), 107; not always tubercular, 111. 

Phytolacca in Corpulency, 171. 

Picric acid (Carbazotate of Ammonium), in Tachycardia, 715. 

Piles, 432. 

Pilocarpine, in Bright's disease, 616 ; in Congestion of the brain, 890 ; in Dropsy, 589. 

Piperazin, in lithsemic Gout, 485; in Renal colic, 580. 

Pleurisy, acute, 353 ; dry, fibrinous or plastic, 353 ; sero-fibrinous, with effusion, 353. 

Pleurodynia (see Myalgia), 194. 

Pneumogastric nerve, its functions in Cough, 258. 

Pneumonia (Broncho-pneumonia), 336; catarrhal, 336; croupous, 342; Heart 
in, 756. 

" Pockets," rectal, 444. 

Podagra (see Gout), 196. 

Poliomyelitis, acute anterior, 969; chronic, 989. 

Polyneuritis, 960. 

Posture in Asthma, 295. 

Pregnancy, Chorea in, 847. 

Prevention, of Cholera, 99; of Tuberculosis, 112, 113. 

Primary lateral sclerosis, 984. 

Procidentia recti, 437. 

Proctalgia, 450. 

Proctitis, 396, 447. 

Prostate, Atrophy of the, 676; Hypertrophy of the, 666; Inflammation of the, 
acute, 656, chronic, 661. 

Prostatorrhcea, 664. 

Pruritus ani, 450. 

Ptomaines, a cause of Headaches, 914. 

Ptyalism, 364. 

Pulse, 787; how to feel it, 793; in meat-eaters, 885; in Peritonitis, 455; inter- 
mittent, 801 ; intermittent in Biliousness, 497 ; irregular, 799 ; rapid (see 
Tachycardia), 691; slow (see Bradycardia), 724; water-hammer or Corri- 
gan's, 685. 

Purdy, Dr. Charles, on Diabetes, 174; prognosis in Diabetes, 179. 

Purpura, 212. 

Pysemia, 210. 

Pyelitis, 619. 

Pyonephrosis, 619. 



Quinine, in Sunstroke, 883; useless in Bronchitis, 306; useless to break up a 

cold, 240. 
Quinsy (see suppurative Tonsillitis), 366. 



INDEX. 1031 

R. 

Rachitis (see Rickets), 227. 

Rectal pockets, 444. 

Rectum, diseases of the, non-surgical, 426; fissures of the, 440; Diphtheria of 

the, 453; hygiene of the, 427; Neuralgia of the, 450; prolapse of the, 437; 

prolapse of the, in children, 439; Ulcer of the, 440. 
Relapsing fever, 16. 
Retention of urine, 654. 
Remittent fever, 10. 
Rheumatism, acute inflammatory, 139; muscular (see Myalgia), 194; Rhus tox. 

in, 144; Salicyl compounds in, 140 — 142. 
Rickets, 227; diet in, 235. 
Rixa, Dr. Alex., treatment of Hay fever, 255. 
Rocky mountain fever, 32 ; a species of Typhoid, 33. 
Romberg's sign, 979. 
Roetheln, "German measles," 51. 
Roseola, epidemic, 51. 
Rubeola, 46. 

S. 
Sacculi Horneri, diseases of the, 444. 
Salicin and salicylates in acute Rhumatism, 140 — 142; in inflammation of the 

heart, 681. 
Salol, in Cystitis, 635 ; intestinal antiseptic in Typhlitis, 410. 
Salt, normal solution of, in Cholera, 105. 
Sansom, Dr., « The Rapid Heart," 722. 
Saprsemia (see Septicaemia), 209. 
Saw palmetto, in Malnutrition, 173. 
Scarlet fever, 40; Arsenic in, 42; Belladonna in, 41. 
Schott's treatment of Heart disease, 828. 
Sciatica, 951; cured by purgatives, 953; in Typhlitis, 409. 
Sclerose en plaques, 973. 
Sclerosis, amyotrophic lateral, 989; disseminated, 973; insular, 973; multiple, 

973; of the arteries (see Arterio-sclerosis), 814; of the veins (see Phlebo- 

sclerosis), 811; primary lateral, 984. 
Scorbutus (see Scurvy), 217. 
Scrofula (see Tuberculosis), 107, 110. 
Scurvy, 217; infantile, 218. 
Se'e, Germain, cold water in Typhoid fever, 18. 
Senile heart, 731. 

Septicaemia, 209; progressive, 210. 
Sewer-gas fever, 28. 
Shingles, 946. 
Silver, in Tabes, 982. 
Small pox, 37. 

Smart, Charles, fever germs in melting snow, 33. 
Smith, Dr. A. H., " The Heart in Pneumonia," 756, 758. 
Smith, Dr. Eustice, Arsenic in Scarlet fever, 42; article on Rickets, 227 — 235; 

Belladonna in Scarlet fever, 41; period of incubation in Scarlet fever, 40; 

symptoms of Capillary Bronchitis, 337. 
Somnambulism (see Epilepsy), 856. 
Sound, urethra], in renal Colic, 583. 
Spanking, a remedy for incontinence in children, 650. 
Spasms, in Rickets, 233; of the glottis in child crowing, 277. 



1032 INDEX. 

Sphygmograph, 792. 

Spigelia, in Tachycardia, 709. 

Spina bifida, 997. 

Spinal cord, inflammation of the (see Myelitis), 967; Tumors of the, 997. 

" Spinal Epilepsy," 973. 

Spinal irritation, 931. 

Spinal neurasthenia, 931. 

Spleen, congestion of the, 560; hypertrophy of the, common in Rickets, 566; in- 
flammation of the, 563. 

Splenalgia, 565; pleuritic pain of, 565. 

Splenitis, 564:. 

Spongia, in Goitre, 203. 

Sputum, in Gangrene of the lung, 349. 

Squill, in Broncho-pneumonia, 340; in Pleurisy, 357. 

St. Vitus' dance (see Chorea), 837. 

Stenocardia (see Angina pectoris), 749. 

Stenosis, nasal, 273. 

Stenosis of the aorta, 687; of the mitral valve, 689. 

Stiff neck (see Myalgia), 194. 

Stomach, Cancer of the, 394; dilatation of the, 382; diseases of the, 370; hem- 
orrhage from the, 387; neuroses of the, 384; Ulcer of the, 389. 

Stomatitis, aphthous, 361; gangrenous, 363; materna, 362; parasitic, 362; sim- 
ple, 361 ; ulcerative, 362. 

Strychnine, a heart tonic, 682 ; a heart tonic in Pneumonia, 348, 766 ; after a cere- 
bral hemorrhage, 917; in Bronchorrhcea, 325; in chronic Gastritis, 376; in 
senile Heart, 741; in spinal Anaemia, 933; in Tetanus, 82. 

Sumbul, in Hysteria, 860, 861. 

Sunstroke, 880. 

Syphilis, 83. 

Syringo myelia, 996. 

Syzygium (Jambol), in Diabetes, 184. 



T. 

Tabes dorsalis, 978; (Neuro-tabes), 961. 

Tachycardia, paroxysmal, 691 ; persistent, 701 ; Spigelia in, 709. 

Taenia mediocanellata, 1013. 

Taenia solium, 1012. 

Tape worms, 1012. 

Temperature, high in Tetanus, 80. 

Tension arterial, high, 768, 794; low, 779, 794. 

Tetanus, 80; caused by bacillus, 80; high temperature in, 80. 

Thompson, Sir Henry, " Diseases of the Prostate," 656. 

Thorn, Dr. R., influence of the dwelling-house on Consumption, 129. 

Thrombosis, 804; of the veins, 804; of the heart and arteries, 813. 

Thrush (see parasitic Stomatitis), 362. 

Thyroid gland, congestion of the, 201; diseases of the, 201; inflammation of the, 
acute, 201; (see Goitre). 

Tonsillitis, acute, 365; chronic, 367; connected with Rheumatism, 365; parenchy- 
matous, 366; suppurative, 366. 

Tonsils, diseases of the, 365; enlarged, the cause of Cough, 264. 

Tracheotomy, in Laryngitis, 286. 

Tremor, a symptom of Sclerosis, 973; cordis, 745; (see Paralysis agitans), 834. 



INDEX. 1033 

Tuberculosis, a consequence of Measles, 47; acute, 110; climate for, 117 — 131; 

climate for, best, 127; diet for, 132; duration of, 112; geography of, 107; 

Lymph glands in (Scrofula), 110; mode of infection, 108; nervous origin 

of (Dr. T. H. Mays), 109; prevention of, 112 — 113; pulmonary (three forms 

of), 111; treatment of, 113 — 135. 
Tumors of the brain, 917; of the spinal cord, 997. 

Turkish baths, dangerous in acute Bronchitis, 30G ; dangerous in acute Coryza, 241. 
Turpentine in Sciatica, 955. 
Typhlitis, 396; (see Appendicitis), 408. 
Typhoid fever, 17; diet in, 27. 
Typho-malaria, 14. 
Typhus fever, 15. 

U. 

Ulcer, of the duodenum, 389; of the rectum, 440; of the stomach, 389. 
Uraemia, G22; headache of, 912; manifested by slow pulse, 725, 730. 
Urethra, irritable, G42. 
Urine, examination of, in Diabetes, 177; incontinence of, G47; retention of, G54. 



V. 

Valvular diseases, chronic, G83. 

Varicella, 39. 

Variola, 37. 

Varioloid, 39. 

Varix, 807. 

Veins, dilatation of the, 807; diseases of the, 803, varicose (see Varix), 807. 

Ventilation in Asthma, 294. 

Veratrum, compared with Aconite, in Pneumonia, 761; in Bright's disease, 604; 

in cerebral hemorrhage, 915; in congestion of the brain, 888; in hyperremic 

headache, 901. 
Vertigo, of arterio-sclerosis, 815, 817; of cerebral tumors, 918. 
Vomiting of large quantities of food a sign of dilated stomach, 382. 



W. 

Whooping cough, 72. 

Winter cough (see chronic Bronchitis), 307. 

Winterburn, Dr. J. W., monograph on Purpura, 214. 

Woman, vesicle disorders of, 638. 

Wood, Dr. H. C, treatment of Rheumatism, 142. 



X. 

Xerostoma, 364. 

Y. 

Yellow fever, 35. 

Yeo's, Dr. I. Burney, Chlorine Water and Quinine mixture in Typho-malarial 
fever, 15; free Chlorine in Typhoid fever, 24. 


















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